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S. HRG. 109–365

FORGOTTEN VETERANS: IMPROVING HEALTH

CARE FOR RURAL VETERANS

HEARING

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS

UNITED STATES SENATE

ONE HUNDRED NINTH CONGRESS

FIRST SESSION

AUGUST 16, 2005

Printed for the use of the Committee on Veterans’ Affairs

(

Available via the World Wide Web: http://www.access.gpo.gov/congress/senate

(II)

COMMITTEE ON VETERANS’ AFFAIRS

LARRY E. CRAIG, Idaho, Chairman

ARLEN SPECTER, Pennsylvania

KAY BAILEY HUTCHISON, Texas

LINDSEY O. GRAHAM, South Carolina

RICHARD BURR, North Carolina

JOHN ENSIGN, Nevada

JOHN THUNE, South Dakota

JOHNNY ISAKSON, Georgia

DANIEL K. AKAKA, Hawaii

JOHN D. ROCKEFELLER IV, West Virginia

JAMES M. JEFFORDS, (I) Vermont

PATTY MURRAY, Washington

BARACK OBAMA, Illinois

KEN SALAZAR, Colorado

LUPE WISSEL, Majority Staff Director

D. NOELANI KALIPI, Minority Staff Director

(III)

CONTENTS

DATE

SENATORS

Page

Salazar, Hon. Ken, U.S. Senator from Colorado ................................................... 1

WITNESSES

Condie, Michael, Routt County Veteran Service Officer ...................................... 5

Prepared statement .......................................................................................... 7

Riedinger, Fred, La Plata County Veterans Service Officer ................................ 9

Prepared statement .......................................................................................... 11

Biro, Lawrence A., Director, Veterans Integrated Services Network 19 ............ 12

Prepared statement .......................................................................................... 14

Murphy, Michael W., Director, Grand Junction VA Medical Center .................. 16

Prepared statement .......................................................................................... 17

Allin, Cephus, M.D., AFGE Member and Employed at the Ft. Collins VA

Outpatient Clinic .................................................................................................. 19

Prepared statement .......................................................................................... 20

Watkins, Charles, Veterans of Foreign Wars, Colorado Department Chief

of Staff, Craig, CO ................................................................................................ 28

Prepared statement .......................................................................................... 29

Stanko, James W., American Legion District 14 Commander, Steamboat

Springs .................................................................................................................. 31

Prepared statement .......................................................................................... 32

Leonard, George, World War II Veteran, Durango, CO ....................................... 34

Richards, Howard, Southern UTE Indian Tribe Past Chairman, Vietnam Vet,

Ignacio, CO ........................................................................................................... 34

Prepared statement .......................................................................................... 35

Rothman, Paula, Gulf War Veteran, Grand Junction, CO ................................... 36

Prepared statement .......................................................................................... 37

Stroncek, Hank, World War II Veteran, Steamboat Springs, CO ....................... 38

Yoast, Leonard, World War II Veteran, Hayden, CO ........................................... 39

Adams, Michael, Iraq War Veteran, Norwood, CO ............................................... 39

Prepared statement .......................................................................................... 40

APPENDIX

Mackenzie, Earl, President, Local 1014, American Federation of Government

Employees, AFL–CIO .......................................................................................... 43

Letters to Hon. Ken Salazar from:

Darrell Anderson .............................................................................................. 44

Erin T. Cavitt .................................................................................................... 44

Tom Gangel ....................................................................................................... 45

Karl B. Gills ...................................................................................................... 46

Paul G. Olson .................................................................................................... 47

T.A. Ottman, USMC ......................................................................................... 47

Gar Williams ..................................................................................................... 47

Letter to Mr. Gar Williams from Sue Lyster ........................................................ 48

(1)

FORGOTTEN VETERANS: IMPROVING HEALTH

CARE FOR RURAL VETERANS

TUESDAY, AUGUST 16, 2005

U.S. SENATE,

COMMITTEE ON VETERANS’ AFFAIRS,

Washington, DC.

The committee met at 9:37 a.m., in the City Hall Auditorium,

250 North Fifth Street, Grand Junction, Colorado, Hon. Ken

Salazar presiding.

Present: Senator Salazar.

OPENING STATEMENT OF HON. KEN SALAZAR, U.S. SENATOR

FROM COLORADO

Senator SALAZAR. Let me go ahead and call the hearing of the

Senate Veterans’ Affairs to order this morning here in Grand Junction, Colorado. I would like to welcome each and every one of you

who is here today. I appreciate your attendance at this hearing.

I also, at the outset, wanted to thank staff from the Veterans’ Affairs Committee that has traveled from Washington to be with us

here today. They are Alex Sardegna and Sara Hofstetter over here

to my left. They do a wonderful job of working with Senator Larry

Craig from Idaho and with Senator Danny Akaka from Hawaii,

along with my other colleagues on the Veterans’ Affairs Committee.

I appreciate them coming down from Washington and spending

some time with us.

To my left are two key people whom I would hope the veterans

of Colorado, and especially those of you on the Western Slope, get

to know. Carlos Monje is my staff on veterans’ issues and has

helped write much of the legislation that we have sponsored in the

Senate on veterans issues. Matthew McCombs who has joined our

staff here in Grand Junction is an Iraq war veteran. Matthew just

recently returned from Iraq, and he will be working with us here

in the Grand Junction office and, hopefully, addressing some of the

issues and helping us address some of the issues that we are working on today.

Way at the left standing in the doorway is Bennie Milliner.

Bennie Milliner is a Vietnam era vet who is on my staff and also

in charge of working on veterans issues for us here in Colorado. So

thank you all for being here.

Now, we are here this morning to examine the challenges that

rural veterans are facing across Colorado. I want to thank the veterans and the volunteers and all of the State and Federal officials

who are here today at this hearing.

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When I went to Washington as a U.S. Senator for the State of

Colorado, I asked to serve on the Veterans’ Affairs Committee. I

did so because I believe that the freedoms that we enjoy in this

great Nation of ours and the celebration of democracy that we engage in every day, including what we are doing here today, is a result of the great actions that today’s veterans and the veterans of

the past have taken to defend the democracy and the freedoms that

we so enjoy here in this country today. So my work on the Veterans’ Affairs Committee is my way of saying thank you to all of

you veterans, to my father who is a proud soldier of World War II,

my brothers who have served, to my uncle who left his life on the

soils of Europe defending our country in World War II. My service

on that committee, hopefully, will make a difference as I work with

my colleagues on that committee to address the issues that our veterans face around our country.

I have been honored to work on that committee to resolve some

of the issues that we have faced even in this last year, including

the billion-dollar shortfall that we had with respect to funding for

health care for veterans and joining my colleagues in a successful

amendment that we passed in the Senate to have another billionand-a-half dollars for health care for veterans just for this year

alone to build that shortfall. I am also working with the Veterans’

Affairs Committee to make sure that we avoid a similar budgetary

problem in the future.

Here in Colorado, closer to home, we have worked very closely

with my colleagues, both in the House of Representatives and the

Senate and with former Secretary Principi and now Secretary

Nicholson in moving forward with what, hopefully, will become a

crown jewel of veterans health care in America, and that is a new

hospital that is being planned or proposed for construction at Fitzsimmons. That hospital should be a state-of-the-art facility because

of the other hospitals and health-care expertise that is going to be

located at Fitzsimmons. We hope that is a project that we can

bring to reality. I appreciate the efforts of Secretary Nicholson and

Secretary Principi and the staff of the Veterans Administration

working with us on that project.

My family has farmed the same lands in the San Luis Valley

now for almost 150 years. It was on that ranch, as I was growing

up as a young man, where we didn’t have a telephone and we

didn’t have electricity. It wasn’t until 1981 that the phone lines

and the power lines reached out to our ranch. Although we were

poor in material goods, we were rich in the spirit and the values

of our parents.

During World War II, as I said earlier, my father was a soldier

in World War II, spent time in Hawaii during the days of Pearl

Harbor. Four years ago he died at the age of 85. He was forever

proud to have been a veteran. He was a lifetime member of the

VFW Post 4849 in La Jara, Colorado in the San Luis Valley. Before

he passed away he asked us to bury him in his World War II uniform, because he was so proud of his service to our country.

My mother at the age of 20 came from a village that had no

name, and, yet, was working with that greatest of generations in

the War Department at the time making sure that we defended our

country from that great world war.

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As I have gone to Washington as a U.S. Senator for Colorado, I

believe that some of the values that we had in the past to make

sure we were supporting those who defended the cause of freedom

and those who have stood up for rural America, that we have not

given it as high a priority as perhaps we should. You know, I come

from one of the poorest and most rural counties in the State of Colorado. I know that in rural America we sometimes face challenges

that are not faced in communities where you have populations of

100,000 or two-million people. It was my decision to go ahead and

ask the Veterans’ Affairs Committee to hold this hearing here in

Grand Junction so we could learn more from the VA on how we can

better serve our veterans in rural areas and how we can address

the issues that the Veterans Administration currently has questions about health care.

Rural America has given up its sons and its daughters to the

cause of freedom in numbers that far exceed its proportion of the

country’s population. These American heroes have not sought

praise or thanks. They came back from the battle field, rejoined

their communities, and quietly went to work as Americans. They

have done their job to serve Americans. We must, as a Nation, do

our job in now keeping our commitment to the nation’s veterans.

Veterans in rural areas are in poorer health than their urban

counterparts. A 2004 study found that rural veterans scored worse

than urban veterans, both in overall health and mental health. Because of the distance and difficulties of obtaining care, many rural

veterans put off preventive as well as necessary treatment which

results in poor health and ultimately increased health costs.

In Colorado more than 65,000 veterans live in rural communities. Thousands more live in small towns that are spread across

our great state. In too many rural corners of Colorado there are isolated pockets of veterans who do not have access to VA care.

We have on our panel two representatives from the VA. I have

to give Mike Murphy and Larry Biro credit for running outstanding

programs. VISN 19 has consistently been rated at the top as a

service network in the Nation and here in Grand Junction. I know

both of you and thousands of VA and employees are doing great

work to improve care for rural veterans within a very tight budget

that you cannot fully control. I appreciate the work that you do on

those issues every day. I look very much forward to hearing from

you.

Clinic access, we will hear from veterans in northwestern Colorado who have to drive as many as 360 miles round trip through

windy mountain roads to reach the VA Medical Center in Grand

Junction. Many of them have to make this trip just to have basic

checkups or to fulfill their prescriptions. This is a grueling trip that

takes an economic and physical toll on our veterans and leads

many to not seek care.

I believe that we need additional VA outpatient clinics in rural

Colorado. For too long tight budgets and bad priorities have slowed

the building of new clinics across the country. Earlier this year I

introduced legislation that would have set aside 150-million dollars

over several years to establish new clinics for rural America. Even

though a bipartisan group of 12 Senators co-sponsored this amendment, it was not approved this year. I hope to work with both my

4

Democratic and Republican colleagues on the Veterans’ Affairs

Committee to move forward with this initiative for next year. I look

forward to the support of veterans’ service organizations in this

particular effort.

Today we also will hear from veterans across southern Colorado

who have access to extremely good VA clinics but have to face administrative red tape and often lack the specialized care in those

communities.

We will hear a representative of the Southern Ute Tribe where

we will hear the unique challenges that Native Americans and veterans for Native Americans face in our country.

We will also hear from brave and dedicated State officials in veterans’ groups who are providing transportation services to rural

veterans. Often these transportation programs are created on shoestring budgets with volunteered drivers and borrowed vehicles.

Such programs currently exist out of the people who support those

programs in Alamosa, in La Plata County, Moffat, Prowers, Weld

Counties and even VSO’s in Denver, Colorado. These are successful

programs, but financial constraints place these programs in jeopardy.

I introduced Senate bill 1191, the VetsRide Act, to help programs

like these survive. The bill provides small grants to State veterans’

service officers and veterans’ service organizations that help provide transportation to VA medical centers or otherwise assist in

providing medical care to veterans in remote rural areas. This bill

has earned the support of 10 Senate co-sponsors including 5 influential Republican and Democratic Senators. I am negotiating with

my colleagues on the Senate Veterans’ Affairs Committee to get the

legislation approved so that we can continue these transportation

programs that are a lifeline to many rural veterans.

Today we also will discuss a number of other important ways

that the VA can extend care into rural areas in a cost-effective

way. The first is a fee basis or contract care. To provide, the VA

can pay for routine care for local third-party providers if the VA

cannot provide that care itself. Fee-basis care can be an important

tool in extending health care to rural vets.

Unfortunately, the VA’s fee-basis policies vary widely across the

country, and the weak budgets that we have provided to the VA

has left thousands of rural veterans without the care that they

would otherwise receive.

The second is tele-medicine. Although nothing can replace the

personal touch of a medical professional, tele-medicine can extend

care and improve lives of veterans. For instance, tele-medicine can

allow the diabetic veteran to keep in close contact with their doctors even if they are hundreds of miles away.

I recently heard from a Denver psychiatrist who was issuing telemedicine to treat rural veterans in La Junta and Alamosa for Post

Traumatic Stress Disorder. This technology holds great promise,

but right now it impacts a very small percentage of veterans. We

need to invest in these technologies so that rural veterans can have

access to better care.

At the heart of many of these problems is a need for additional

VA funding. I personally believe we need to make funding for the

Veterans Health Administration mandatory so that the VA never

5

has to ration care and so the veterans never have to worry about

losing their health care.

Rural areas are the heart of our forgotten America, and rural

veterans too often are our forgotten veterans. I look forward to

hearing the testimony of our witness and working together to keep

our promises that our Nation has made to all of our veterans including rural vets.

Before we proceed to the first panel, I would like to go over a few

ground rules established by the Committee on Veterans’ Affairs for

this hearing. Because of the time constraints of this hearing, we

will have to limit today’s oral testimony to the witnesses approved

by the Committee. I understand that many of you have concerns

and experiences you would like to share, and I would like to keep

the official record open so that your written testimony can be part

of the record of this hearing. My staff has testimony forms that you

can fill out, and you can fill them out here and return them to my

office via the instructions that are laid out in that form.

Second, I will ask the witnesses today to limit their important

testimony to 5 minutes. We have a card system in place to remind

you of when your time is expiring. Matthew will hold those times

up. Green means you go, just like a traffic light. Yellow means you

have 1 minute left, so be careful. Red means your time is up. We

have a large number of witnesses, so I will ask the witnesses to

hold their comments down to the time that we have allotted.

In our first panel we will hear from Federal and State officials,

and in our second panel we will hear from the veterans’ service organizations.

Our first panel will consist of Michael Condie who is the Routt

County Veterans Service Officer.

Fred Riedinger who is the Veterans Service Officer for La Plata

County.

Larry Biro who is Director of Veterans Integrated Service Network 19, and who has done a great job working with us on the

Fitzsimmons project.

Dr. Mike Murphy who is the Director of the Grand Junction VA

Medical Center.

And Dr. Cephus Allin who is a member of the American Federation of Government Employees who works at the Ft. Collins VA

outpatient clinic.

With that, I am going to ask Mr. Condie to please proceed.

STATEMENT OF MICHAEL CONDIE, ROUTT COUNTY VETERAN

SERVICE OFFICER

Mr. CONDIE. Well, one of the things that is interesting about this

whole thing is—thank you very much for having us here from

Steamboat Springs. I did send a number of pieces of paper, literature, to Carlos Monje, letters from the Yampa Regional Medical

Center, letters from the Mental Health District, and a letter from

myself.

Specifically, I want to say living in a rural area, which you are

quite familiar with, is rather trying to begin with. I also have a

map here that I want everyone to see about the empty quarter. We

are considering the empty quarter. We have nothing. We have no

representatives from the VA in our northwestern Colorado. Travel

6

takes roughly 31⁄2 hours starting in Steamboat Springs to Grand

Junction. It’s 191.5 miles one way from Steamboat Springs to the

Grand Junction VA Hospital. So, essentially, the day is shot for an

individual.

What I do is, like what I did today, is I rent a vehicle from the

Ford dealership in Steamboat Springs, hire a driver, usually a veteran who is unemployed to drive. Because a volunteer from that region to drive a vehicle down to Grand Junction or to Denver, you

aren’t going to do it. It doesn’t happen.

Even though I approached both the VFW and American Legion

membership to be volunteers, they say they will do it at the moment, but when it comes down to the time when you need a driver,

it doesn’t happen. So I pay the drivers $75 for the round trip, rent

a vehicle. Like today, I rented a six-place Ford Explorer 2005. I get

a pretty good deal because the owner/manager of Steamboat Motors

Ford Dealership is an Army veteran, so they provide me a better

deal on rental vehicles.

But, other than that, the veterans who utilize the transportation

system, which I created 4 years ago, because I kind of got angry.

There was a veteran who needed transportation to the VA hospital

at least four times a year to take care of physical issues, a World

War II veteran. It took so much from his family to get him down

here, whereas, something had to happen.

What happened was I started writing grants. I have been writing

grants for the last 4 years to obtain funding. I write grants through

the Veterans Trust Fund of Colorado. For this year, I wrote a grant

through the Yampa Foundation, which is an organization that

comes out of Steamboat Springs. I planned to write a grant in October through the Yampa Electrical Association. So that tells me

that those folks and the public in general support the veterans, and

they support veterans’ issues.

I get the money from grants. I put the funding in Alpine Bank

at Steamboat Springs. It’s in an account that doesn’t cost me anything, and it’s an interest-bearing account. Not a whole lot of interest, but, hey, it’s something. Veterans who need transportation, can

get transportation to the Denver VA Hospital or to the Grand Junction VA Hospital on demand.

Today the vehicle that I rode in transported five veterans. I have

another vehicle that’s leaving Steamboat Springs at 9 o’clock that

will transport one veteran, and he’s a World War II veteran, served

in the Pacific. The two veterans that came with me, the two older

veterans that came with me, are World War II veterans. One veteran worked with the Army Air Corps in the Pacific. The other veteran was with the Coast Guard, and he served in the Atlantic and

he served in the Pacific. These guys have seen a lot, and they utilize the VA system because health care in Routt County in northwestern Colorado is expensive. It’s hard for veterans to be able to

pay for and acquire affordable health care.

The thing here, is that what takes place for the veterans of Routt

County—well, it looks like I got 1 minute left, sir—what takes

place in Routt County is that having a CBOC, or a CommunityBased Outpatient Clinic, does not mean concrete and bricks. It

means contract. We have three major hospitals on Route 40. We

7

have a hospital in Kremmling, we have a hospital in Steamboat

Springs, and we have a hospital in Craig.

Steamboat Springs is the newest. They have a very good and

technically advanced infrastructure. The thing here is the care and

the interests of all three hospitals, in their conversations with the

VA, are very interesting. There are doctor groups up in Steamboat

Springs that would like to have an interest with the VA and/or a

contract with the VA. Realistically, having a contract would be the

best thing to do. Having a contract in one of the better hospitals

would be the best deal for the veterans in that region.

I did bring a map, and I will either show it or provide it to this

panel. Like I was saying earlier initially, northwest Colorado is the

empty quarter, but, yet, in Routt County alone we have over 1,800

veterans, in Moffat County a similar amount. We do need something in northwestern Colorado.

If the Senator is interested in looking at the map, you can look

at it real quick, and then I will shut my mouth and move on, sir.

Senator SALAZAR. I think there is probably a copy that shows the

empty——

Mr. CONDIE. Well, it’s a bigger map, sir.

Senator SALAZAR. Oh, it’s a bigger one. Go ahead and show it.

Mr. CONDIE. OK. Right here in this area, sir, in northwestern

Colorado, the reason why I have it circled, it’s the empty quarter.

There is nothing there.

Down here where I have only orange spots, these are either a

hospital here, CBOCs in these three locations, and all these locations are CBOCs and hospitals here. Essentially the eastern part

of Colorado and southern part of Colorado got all the CBOCs.

Northwestern Colorado got nothing, and we need something.

[The prepared statement of Mr. Condie follows:]

PREPARED STATEMENT OF MICHAEL CONDIE, ROUTT COUNTY VETERAN

SERVICE OFFICER

It’s important to understand the problems of living in a rural area with limited

resources that provide human services to the existing population. There are numerous subcultures in this region. The agrarian, recreational and the sub-subcultures

that support both regional activities cause this area to be attractive to the population. A percentage of this population is made of Military Veterans who inhabit all

facets of the subcultures that make up the social structure of the region.

What this letter is going to concentrate on is the military veteran. The military

veteran lives in this region for numerous reasons. They were born and raised here,

or they moved here for a better life. The military veteran had earned many benefits

for serving in this country’s military—the most important is health benefits. The

problem with accessing this benefit earned is the long distances to VA Facilities located in metropolitan areas that have high density of population. These long distances equal hundreds of miles round trip from where the veterans live. As the veteran population ages, the ability to access this benefit becomes more difficult. This

difficulty is exacerbated by weather and road conditions—lack of public transportation and the infirmities of the veteran. The physical infirmities are caused by life

style, service-related injuries or old age.

Just getting to a VA facility can be troublesome because of the limited routes

available. There are three routes from this region that terminate at Interstate 70.

Route 40 over Rabbits Ears pass, Route 13 out of Craig, or Route 131 connecting

to Route 40 out of Steamboat Springs. All routes are fraught with the difficulties

of winter, elk and deer migratory movement and potentially difficult road conditions.

Let’s concentrate on getting to I-70 during the daytime (night travel on these

routes becomes inherently difficult because of aforementioned hazards). During the

winter, travel becomes difficult to impossible. Blowing snow, snow buildup on the

roads, coupled with the isolation of the road routes causes major difficulties for travVerDate 11-MAY-2000 13:20 May 04, 2006 Jkt 025787 PO 00000 Frm 00011 Fmt 6633 Sfmt 6621 C:\VA\25787.TXT CarolB PsN: CarolB
8

elers. Periodically, Rabbit Ears Pass is closed because of snow, requiring use of

Route 131 or Route 13 to access I-70. Traveling Route 131 from Steamboat Springs

to Wolcutt is not recommended especial1y during the winter. Route 13 from Craig

to Meeker, and from Meeker to Rifle, is difficult during winter months, and the population in this region is isolated. Once I-70 is reached, a veteran would go west to

Grand Junction or east to Denver. The Routt or Moffat County Veterans Affairs Offices provide transportation for needy veterans either to Denver or Grand Junction

VA Medical Facilities.

The Veterans Transportation Fund was created by the Routt County Veterans Affairs Officer to provide transportation for veterans in Routt County who cannot or

do not drive or have infirmities. The Moffat County Veterans Affairs Officer had a

vehicle donated by the local Ford Dealership in Craig. The Routt County Veterans

Affairs Officer writes grants to obtain funding rents vehicles from the Ford dealership in Steamboat Springs, hires an unemployed veteran with a good driving record

and good insurance at $75 per trip. This vehicle then picks up veterans at prearranged locations. The first location is the Veterans Affairs Office in Steamboat

Springs; the second location is the American Legion Hut in Hayden; the third pickup spot is McDonalds restaurant in Craig, and the fourth location would be at the

office building where the Rio Blanco VSO is located.

Currently, transportation for veterans has been solved to a certain extent but is

still an issue in the northwestern part of Colorado. There are some veterans who

could get to the VA facilities on their own even without a vehicle, if there was public

transportation availab1e. There is no public transportation from the northwest region of Colorado to the metropolitan areas where VA facilities are located. The only

transportation system in this region is with expensive Alpine Taxi to the Denver

Airport with one stop on the way at I-70 and Kipling St. Veterans with a fixed income cannot afford the taxi service; however, the Veterans Affairs Officer of Routt

County provides funds to purchase round-trip taxi tickets for veterans upon request.

(Call DAV Disabled American Veterans located at the Denver VA Hospital and arrange for transportation from and to Kipling and I-70.)

Another issue for consideration is CBOC (community-based outpatient clinic) in

this region to take care of veterans. Understand a CBOC is not a concrete and brick

structure but a contract with an existing medical facility with the infrastructure

that has the ability to provide health care to veterans. There are those who advocate

providing VA services at the three major hospitals in this region: Yampa Regional

Medical Center, Steamboat Springs, hospital in Kremmling, Memorial hospital in

Craig. That may work in a perfect world; however, reality dictates a CBOC centralized in the northwestern region. Getting a CBOC in the northwest region of Colorado requires careful thought and the understanding that it will cost the VA more

money. Further, a CBOC will have to accommodate veterans from a large geographical area, including Moffat, Routt, Rio Blanco and Grand Counties. Potentially,

veterans from Eagle and Jackson Counties and upper Garfield County could use a

CBOC centralized in northwestern Colorado to include lower portions of Wyoming.

This is all conjecture, but it is important to verbalize thoughts to show cause for

an idea to materialize. The (5) counties that make up northwestern Colorado encompass 13,788 square miles of area. The prevailing rational is going to apply to Veteran density; hence, the location of CBOC’s in Colorado. Northwestern Colorado is

never going to meet VA rules that govern location of a CBOC because the population is too spread out. One wonder’s why the Administration in charge of VISN–

18&19 would have planned to have a CBOC in each quadrant of Colorado, and then

place other CBOC’s where needed based on the growing veteran population. ‘‘Alas’’

they didn’t. It’s clear to me that the long view didn’t factor in the planning stage

of locating CBOC’s in Colorado.

The long view I refer to is tied into the growing veteran population in northwestern Colorado. ‘‘So,’’ the bottom line is, veterans are required to drive great distances to procure a benefit earned. The veterans of northwestern Colorado get shortchanged. Money was spent to accommodate the veterans on the East Coast of the

United States and the eastern slope of Colorado as well as for continued maintenance and upkeep on cement and bricks of aging buildings. It makes a person wonder why some VA facilities can’t be consolidated and the funding redirected to the

have-nots.

The military is going through down-sizing and reorganization with BRAC—why

can’t the VA follow the same process? Let’s call it VARC (veterans affairs reorganization and consolidation). ’The problem with northwestern Colorado is it’s out-ofsight and out-of-mind.

As Always, Semper Fi.

9

Senator SALAZAR. Thank you, Mr. Condie, for your service to our

veterans and for your testimony.

Fred Riedinger, from the VSO from La Plata County.

STATEMENT OF FRED RIEDINGER, LA PLATA COUNTY

VETERANS SERVICE OFFICER

Mr. RIEDINGER. First, Senator, I would like to thank you for coming to this area and for giving us this opportunity.

To quote from the latest issue of the VFW Magazine, ‘‘We know

how to turn civilians into soldiers, but not soldiers into civilians.’’

To this we add a veteran is trained to turn off hunger, thirst and

pain to get the job done. He continues living this style when he returns to civilian life. Most take the position he served his country

to protect it and wishes not to be a burden when he returns to civilian life.

Although veterans face many of the same issues of veterans in

other rural areas, we seem to be more isolated with access over a

number of major passes.

There are a number of good things happening here: The care at

our local VA-contracted clinic with Health Net Federal Services has

become outstanding and stand out in the VA clinic system. The

health care delivered from Albuquerque VA Medical Center is excellent, and I regularly receive favorable comments from the veterans and their families about both the service and staff. Our local

VA clinic has received recognition for excellence from Health Net

Federal Services.

Since January 2002 there has been local collaboration to provide

assistance to veterans and their families.

Senator SALAZAR. Excuse me, just one second. Can everyone

hear? Is the microphone on?

Mr. RIEDINGER. I think so.

Senator SALAZAR. Speak up just a little bit so——

Mr. RIEDINGER. Sorry.

Senator Salazar [continuing]. We can make sure we have everybody hear.

Mr. RIEDINGER. Since January 2002 there has been local collaboration to provide assistance to veterans and their families. The Veteran Service Office of La Plata, La Plata County Human Services,

Southern Ute Veterans Association, Veterans of Foreign Wars Post

4031 and its auxiliary, the Durango Army National Guard Family

Assistance Center, the Durango Blue Star Moms Chapter 1, the

Durango Disabled American Veterans Chapter 48, private citizens

and veterans’ families provide 24/7 support in various ways.

Resources to fund these efforts have always been slim but are

even more difficult to generate now. The needs have not diminished, but the funding has. Coldwell Banker has partnered with

the veterans’ organizations to raise funds for a matching grant that

allowed us to acquire two DAV vans and two electrical scooters.

This business is committed to further projects for vets.

The VSO’s from La Plata County, Archulta and San Juan Counties work cooperatively in enrolling veterans into the Durango VA

clinic.

10

However, these successful efforts should be supplements to and

not a replacement for the VA providing funding to the degree we

presently need. Your 1191 is going to go a long ways toward that.

The Colorado Board of Veterans’ Affairs provides grants from

their share of the Tobacco Settlement. These funds provide the

mainstay for our transportation program now. Of great concern is

the fact that these funds will be gone in 2007. This is where your

H.R. 1191 is going to make a big difference. The VA Veterans Service Center in Denver has provided assistance and advice that has

made this office efficient, has been instrumental in our successful

service to veterans, and is deserving of a compliment from you,

Senator.

Several matters are not positive and would benefit from more

permanent solutions.

There have been changes in the overnight accommodations for

the Albuquerque VA Center. The funding has been severely restricted for per diem and overnight stays.

This has resulted in veterans canceling compensation and pension examinations. For those that go, they may be asked to stay

overnight and have to do so at their own expense. It is important

to know that many of these individuals are World War II veterans

who are in medical need and often financial need as well.

In addition, the requirements for physical exams for drivers have

become burdensome. This has resulted in a loss of 13 drivers for

our DAV vans. I am down to one driver now. I originally had twenty-two volunteers, but they are restricted.

This further complicates trying to get someone to Albuquerque

for examinations. It would be helpful if the rules were the same at

the various centers, as Grand Junction does not have the restrictions on overnight and per diem that Albuquerque has.

I will provide additional information to staff regarding individual

veterans that I would like to pursue through Senate Salazar’s office.

Thank you for the opportunity to participate in this panel.

I was asked to mention a specific issue. There is a gentlemen

here right now I was talking to about ionization radiation exposure. I have two veterans with documented service-connected problems due to radiation. The overexposure is known. A veteran’s exposure is above what was determined to be overexposure in 1958.

It is now known that the acceptable level of exposure then is far

greater by today’s acceptable level. The evidence is that his fate at

the end of a 2-year study must be completed before a determination

will be made and an award considered. The new standard will only

say his exposure is greater. I believe that compensation should be

awarded based on the evidence submitted, not delayed for a study

that will only determine the extent of overexposure.

Senator SALAZAR. Mr. Riedinger, I appreciate the specific case,

and if you will help me make sure that you get that letter to me,

and we will take up that specific case.

Mr. RIEDINGER. They have been submitted.

Senator SALAZAR. So I appreciate your testimony, and I appreciate what you do for veterans in southwestern Colorado.

Mr. RIEDINGER. Thank you. It’s been submitted, sir.

11

Senator SALAZAR. We will include that in the record, and also we

will take a look at the specific case.

Mr. RIEDINGER. Thank you.

[The prepared statement of Mr. Riedinger follows:]

PREPARED STATEMENT OF FRED RIEDINGER, LA PLATA COUNTY VETERANS

SERVICE OFFICER

ISSUES AND PROBLEMS FACED BY VETERANS IN THE FOUR CORNERS AREA

Although veterans face many of the same issues as veterans in other rural areas,

we seem to be more isolated, with access over a number of major passes.

There are a number of good things happening here.

The care at our local VA-contracted clinic with Health Net Federal Services has

become outstanding and a standout in the VA Clinic system. The health care delivered from the Albuquerque VA Medical Center is excellent and I regularly receive

favorable comments from the veterans and their families about both the service and

the staff. Our local VA clinic has received recognition for excellence from Health Net

Federal Services.

Since January 2002, there has been local collaboration to provide assistance to

veterans and their families. The Veterans’ Service Office, La Plata County, La Plata

County Human Services, Southern Ute Veterans Association, Veterans of Foreign

Wars Post 4031 and its auxiliary, the Durango Army National Guard Family Assistance Center, Durango Blue Star Moms Chapter One, Durango Disabled American

Veterans Chapter 48, private citizens and veterans’ families provide 24/7 support in

various ways. Resources to fund these efforts have always been slim, but are even

more difficult to generate now. The needs have not diminished but the funding has.

Coldwell Banker has partnered with the veterans’ organizations to raise funds for

a matching grant that allowed us to acquire two DAV vans and 2 electric scooters.

This business is committed to further projects for vets.

The VSO’s from La Plata, Archuleta and San Juan Counties work cooperatively

in enrolling vets into the Durango VA Clinic.

However, these successful efforts should be supplements to and not a replacement

for VA-provided funding in the degree we presently experience.

Colorado Board of Veterans Affairs provides grants from their share of the Tobacco Settlement. These funds provide the mainstay for our transportation program

now. Of great concern is the fact that these funds will be gone in 2007.

The VA Veterans Service Center in Denver has provided assistance and advice

that has made this office efficient and has been instrumental in our successful service to veterans and is deserving of a compliment from Senator Salazar.

Several matters are not positive and would benefit from more permanent solutions.

There have been changes in the overnight accommodations for the Albuquerque

VA Center. The funding has been severely restricted for per diem and overnight

stays.

This has resulted in veterans canceling compensation and pension examinations.

For those that go, they may be asked to stay over night and have to do so at their

own expense. It is important to know that many of these individuals are WWII vets

who are in medical need and often, financial need as well.

In addition, the requirements for physical exams for drivers have become burdensome. This has resulted in a loss of about 13 drivers for our DAV vans. This further

complicates trying to get someone to Albuquerque for exams.

It would be helpful if the rules were the same at the various centers, as Grand

Junction does not have the restrictions on overnight and per diem that Albuquerque

has.

I will provide additional information to Staff regarding individual veterans that

I would like to pursue through Senator Salazar’s office.

Thank you for the opportunity to participate in this panel.

Senator SALAZAR. If I may now turn it over to Larry Biro, who

appeared before me in Washington, DC. and the Senate Veterans’

Affairs Committee many times. He is doing great work on behalf

of VISN 19.

12

STATEMENT OF LAWRENCE A. BIRO, DIRECTOR, VETERANS

INTEGRATED SERVICES NETWORK 19

Mr. BIRO. Thank you, Senator Salazar, for giving me the opportunity to speak before you and my fellow veterans on what’s going

on in VISN 19 in terms of delivering care to the rural veteran.

Just a sideline, we left the meeting with Secretary Nicholson, actually a field visit to Fitzsimons, to look at the property yesterday.

Mr. Milner was with us, and at 4 o’clock we looked at that. So we

are working hard on the Denver project and continue to do that.

Senator SALAZAR. Thank you.

Mr. BIRO. So what I will be doing is giving you the overall perspective of VISN 19. Dr. Murphy will talk about the local arrangements here in this catchment area.

As you mentioned already, I would like to re-mention, that the

VA or VHA healthcare program is mentioned over and over as the

benchmark in terms of quality of care, and just as recently as July

18 in US News and World Report an article came out——

Senator SALAZAR. Larry, if I may, can you get the microphone

just a little closer to make sure that everybody can hear you

throughout the room? I don’t know, our sound system is not doing

as well as it should.

Mr. BIRO. OK. The Veterans Health Administration was written

up again in the July 18th edition of US News and World Report

as a health care system second to none.

VISN 19, Senator, as you pointed out, is No. 1. In 2004 our performance measures and our customer satisfaction, or veterans’ satisfaction scores, were the best in the United States. The two hospitals which were the best in our network were Grand Junction

and Denver. So if you want care that is second to none, the best,

the best in the United States, it’s here in Colorado as we stand,

and we are going to do that again in 2005.

Just let me briefly talk a little bit about what’s going on here in

VISN 19. First, we make three promises: First, that the care will

be second to none. The hands-on provision of care to any veteran

will be second to none.

The second, that we will maintain and expand services. We do

not go backwards in 19. We will continue to expand services, and

the issues of providing more care to rural veterans is obviously an

area where we can continue to expand.

The third promise is that each and every veteran will be personally satisfied in the services that they get from our network.

Now, you may be thinking we have had two witnesses say that

they are dissatisfied with access. There are two tracks of satisfaction. One, is the experience the veteran has when they come to one

of our facilities and get care. They need to be personally satisfied.

The second track is the broader of providing care, but we will

stand behind those three promises and to continue to work those

as long as I am here.

The network is large. I think you know it’s 22 percent of the

United States’ contiguous area. It has about 700,000 veterans. It’s

about 2.5 percent of the veteran population. It covers four states

major, Colorado, Wyoming, Montana and Utah, plus about four

other states on the periphery. We have 6 medical centers and 32

13

CBOCs. Right now we are serving about 140-some-thousand,

150,000 veterans. That’s doubled essentially since 1996.

Essentially in your statements you have covered how we deliver

care to the rural veteran. The first and foremost is the communitybased outpatient clinic. We have 32 of them. Some are a direct provision of care by VA employees, some are contract.

If you look at the number, as I said, there are about 800 of these

clinics across the United States. If we were 2.5 percent, we should

have about 17 or 18 clinics, and we have those thirty-two clinics.

So they are all over. I think pretty much everybody is covered

where they are at. There are big ones; there are little ones. The

Colorado Springs clinic is gigantic. You have probably seen it—the

one in Billings, Montana, and they are down as small as 80 people

in Sidney, Nebraska. So we have got clinics, and that’s the first

way we deliver care to the rural veteran is through CBOCs.

The second, as you had mentioned, is that we have a transportation network. We have the biggest transportation network of the

VHA, 21 networks. The statistics are amazing. The DAV transported 26,000 patients for the first three quarters of 2005 traveling

1.4-million miles. The drivers in those first three quarters volunteered essentially 54,000 hours and it continues to go on. We continued to develop that system, and we need it.

The third is tele-medicine. As you mentioned, that’s an emerging

technology that allows the veteran to stay in his home and for us

to get him electronically. Our program is the second biggest in the

VHA. That’s pretty amazing since the biggest program is VISN 8,

which is the biggest concentration of veterans in any area in Florida, so our program is quite large with the goal of expanding it.

Even at that, it’s several hundred at this time. Tele-medicine goes

beyond the individual care. We have link-ups for dermatology, radiology, various tests between Denver, between Grand Junction and

several different areas.

We are very proud of our program with the Native Americans.

We do outreach for PTSD at four reservations right now and plan

to expand to several others.

Just very quickly, CARES was in 2004. In May 2004 they came

out with a CARES decision for VISN 19. We mentioned the new

facility in Denver and three CBOCs. Those three CBOCs were Cut

Bank, Montana; Lewiston, Montana; and the west valley of Utah.

That document gave us to 2012 to complete those CBOCs and open

them.

Our plan was to open them in 2005. Given limited resources, we

did not open them in 2005. Our goal is to open all of them in 2006

then move beyond to look at other CBOCs.

As you mentioned we are constrained to a certain extent by the

directive the VHA has on the size of CBOCs and how they are to

be constructed. That is a challenge. We need to get that directive

changed, because as it stands now rural CBOCs will be disadvantaged. They are not big enough. They don’t meet the requirement.

The resources would be recommended to be put somewhere else.

Once we get our clearance and we establish the CBOCs as recommended by CARES, we will go on to look at all the other CBOCs

that have been requested. That’s the challenge as you have laid

out, and your legislation would help us. I probably have on the

14

docket somewhere between 15 and 20 CBOCs, anywhere between

Colorado, Montana and Utah and Wyoming.

Senator SALAZAR. Fifteen or twenty requested?

Mr. BIRO. Fifteen or twenty requested. All the way from the east

side of Colorado along the Kansas border, all the way over to here,

all the way up into the border of Canada and Montana. My challenge is how do you prioritize those with the resources that I have,

and how do you approach them? There are not enough resources.

There will never be enough money to do everything that everybody

wants to do. That’s what medicine is. But that’s the way we are

going. That would be the plan. Finish the CARES recommendations in 2006, move on with a prioritized list of CBOCs for 2007

and work through those.

So, in summary, I stand behind my three promises, that the care

will be second to none, in 19; that we will maintain and expand

services, and we have. We have expanded by taking care of 5 percent more this year than last year. We are going to continue to expand that way plus programs. We will work on every veteran being

personally satisfied with the services that they have received.

Thank you.

[The prepared statement of Mr. Biro follows:]

PREPARED STATEMENT OF LAWRENCE A. BIRO, DIRECTOR OF VETERANS INTEGRATED

SERVICES NETWORK 19

Senator Salazar and other Members of the Committee, I appreciate the opportunity to appear before you today to discuss veterans’ rural healthcare in VISN 19

and in the State of Colorado, in particular.

I will discuss these issues from an overall VISN perspective and defer to Dr. Michael Murphy, Director of the Grand Junction VAMC whose catchment area includes western Colorado, for issues related to that health care facility.

In a recent article published by the Washington Monthly, Jan/Feb 2005, ‘‘The Best

Care Anywhere,’’ the Veterans Health Administration (VHA) was cited as producing

the highest quality care in the country. In fiscal year 2004, VISN 19 was rated No.

1 within the Veterans Health Administration, as evaluated by the national performance measures and the veteran patient satisfaction scores.

VISN 19 makes three promises to all our veterans regardless of where they live

or where they receive their health care. These promises will be our measures of success: Provide high quality of care second to none; Maintain and expand services; and

Personal veteran satisfaction.

VISN 19 (the VA Rocky Mountain Network) spans an area of 470,000 square

miles across nine states and is, geographically, VA’s second largest health care network. There are over 700,000 veterans residing within VISN 19. VISN 19 serves an

area covering all of Utah; most of Wyoming, Montana, and Colorado; and portions

of Nevada, Idaho, Kansas, Nebraska, and North Dakota. The geographic area contained within VISN 19 varies from highly urban cities, to rural communities, to remote frontier areas. The terrain varies from arid desert to high altitude mountains,

both made more difficult during the winter months. For fiscal year 2005, VISN 19

employs a workforce of 4,650 fulltime equivalent (FTE) employees with an operating

budget of $589 million dollars. In fiscal year 2004, our facilities provided care to almost 142,000 unique patients, up from 80,000 in FY 1996. The number of patients

treated is up an additional 5,000 in fiscal year 2005.

VISN 19 has, from its inception, focused on providing primary care and outpatient

mental health services closer to where veterans live. This focus has resulted in the

establishment of a significant number of clinics throughout the VISN. There are currently 32 Community-Based Outpatient Clinics (CBOCs) in VISN 19. These CBOCs

range in size from small contract clinics such as Sidney, Montana, to large and more

complex clinics such as those in Colorado Springs, Colorado; Billings, Montana; and

Pocatello, Idaho. Clinics in Colorado are located not only in Colorado Springs but

also in Pueblo, Lamar, La Junta, Alamosa, Montrose, Ft. Collins, Greeley, Lakewood

and Aurora.

There continue to be many veterans in VISN 19 who are geographically isolated

from VA health care services. In the past several years, there has been significant

15

interest expressed by Congressional representatives, Veteran Service Organizations,

and individual veterans in establishing new CBOCs at locations throughout the

VISN. These locations include Elko, Nevada; Northwestern Colorado; Eastern Colorado/Western Kansas; and Afton, Wyoming. At the request of stakeholders, VISN

representatives have attended town hall meetings in Afton, Wyoming, Goodland,

Kansas and Elko, Nevada. I have personally met and had extensive conversations

with many Congressional representatives to discuss the possibility of new CBOCs

in several of those and other locations.

The VA Rocky Mountain Network continues to pursue new and innovative approaches to reach veterans in rural, remote and frontier locations. VISN 19 partners

with Veteran Services Organizations such as the Disabled American Veterans, to

provide an external transportation system which is vital to many veterans obtaining

their health care at VA facilities. For the first three quarters of fiscal year 2005,

the DAV transported 25,771 patients, traveled 1,372,863 miles, and volunteered

53,684 driver hours for the VA Rocky Mountain Network. VISN 19 has also been

a leader in the development of Care Coordination Home Tele-health programs and

other telemedicine initiatives which allow veterans to receive their care in their

homes or at remote locations.

In 2003–2004, the Veterans Health Administration (VHA) underwent a landmark

study of VA’s heath care infrastructure known as the Capital Asset Realignment for

Enhanced Services (CARES). Among the elements of the draft National CARES

Plan were proposals to expand the numbers of CBOCs throughout the country. In

VISN 19, there were three public hearings at which stakeholders were provided an

opportunity to comment on the draft National CARES Plan. In May 2004, the Secretary of Veterans Affairs issued his CARES Decision. In that decision, as it pertains to VISN 19, the Secretary identified three new CBOCs as priorities for implementation by 2012. Those were West Valley, Utah, a suburb of Salt Lake City;

Lewiston, Montana; and Cut Bank, Montana.

VISN 19 plans to address other CBOC locations after activating the clinics identified as priorities in the Secretary’s CARES decision. We wanted to activate the three

priority clinics in late fiscal year 2005. However, resources to undertake establishment of these three new CBOCs are not available. Both northwestern and northeastern Colorado may be considered as locations for placement of CBOCs. The veterans who reside in these areas must travel hundreds of miles to access VA health

care often through difficult terrain during the winter months. We will pursue additional CBOCs throughout the VISN as soon as resources allow.

VA criteria for planning and activating CBOCs are contained in VHA Handbook

1006.1. All CBOC business plans must be developed in accordance with this Handbook and approved by VA Central Office. The criteria emphasize the need for sufficient population and workload projections, but other unique factors, such as geographic barriers, travel times, and medically underserved areas, are also taken into

consideration. The business plan must also address the costs and benefits of establishing a VA-staffed CBOC or a CBOC based on contracting with local health care

providers. VISNs must also ensure that resources are in place to open new CBOCs,

including the capacity to manage specialty care referrals and inpatient needs of the

populations to be served. Proposals are scored based on these criteria. Proposals

with high enough scores are approved by VA Central Office. A CBOC proposal in

either northwestern or northeastern Colorado would be evaluated with these criteria

and prioritized within the network.

VISN 19 recognizes successful improvement to veteran rural health care requires

a multi-faceted approach. In order to provide veterans with the high quality health

care they need and deserve, we will continue to encourage VHA as an organization

to fully re-examine our approach to the provision of health care in rural and frontier

areas.

In summary, VISN 19 has experienced a significant workload growth over the

past few years. We have established many new CBOCs throughout the VISN. There

are locations where additional clinics are needed. Our plan is to continue with the

activation of the three CARES priority clinics as resources become available. Additional clinics sites will be seriously considered, proposals developed and submitted

when sufficient funding is identified.

Thank you, Mr. Chairman. This concludes my formal remarks. I would like to entertain any questions the Committee Members may have.

Senator SALAZAR. Thank you, Directly Biro. Now we will hear

from Dr. Mike Murphy, Director of the Grand Junction VA Medical

Center.

Dr. Murphy.

16

STATEMENT OF MICHAEL W. MURPHY, DIRECTOR, GRAND

JUNCTION VA MEDICAL CENTER

Dr. MURPHY. Thank you. I would like to thank you, Senator

Salazar, and Members of the Veterans’ Affairs Committee for the

opportunity to discuss the role and function of Grand Junction VA

Medical Center in serving veterans residing along the western

slope of Colorado and southeastern Utah. We certainly share the

Committee’s interest in providing high quality accessible care to

veterans throughout our service area.

The Grand Junction VA Medical Center is a Complexity Level IV

facility located here in Grand Junction where we have served veterans 55 years. We also operate a staffed CBOC, located in

Montrose. That activity opened in 1999.

Grand Junction’s mission is to provide primary and some secondary-level medical, surgical and psychiatric services which include inpatient care in acute medicine, surgery and psychiatry, as

well as a near full range of primary and secondary medical, surgery and Psychiatric Outpatient Services.

Specialized programs included mental health services, outpatient

substance abuse treatment, same-day surgery, audiology, computerized tomography or CT, and a mobile MRI imaging.

Patients requiring tertiary care are transferred to VA facilities in

Denver or Salt Lake City, and that transfer is accomplished usually by air ambulance. When patients are not stable for transport

to Denver and Salt Lake, we utilize St. Mary’s here in Grand Junction. We also routinely obtain some specialty care on a contract or

fee basis. Through arrangements with St. Mary’s we obtain radiation therapy, cardiac care, and other specialized services. Utilizing

scarce medical specialty arrangements in the community, we are

able to provide urology, ophthalmology, ENT, orthopaedics, neurology and podiatry services.

While these arrangements allow this facility to provide care beyond the spectrum normally expected in a Level IV facility, there

are still some services which we are not able to provide and which

are outside the scope of the mission for a primary care facility. We

are not tertiary facility.

We also have a 30-bed transitional care unit which provides rehabilitation services largely focusing on veterans who have had

strokes, amputations and joint replacements. By the way, Grand

Junction does do hip and knee joint replacements, somewhat remarkable for a Level IV facility.

We also provide traditional nursing home services and hospice

care in our transitional care unit. Our patient service area spans

40,000-square miles which includes the entire western slope of Colorado from Durango to Wyoming. We extend 180 miles east from

the Utah border into the heart of Rockies. We serve the two southeast-most counties in Utah as well.

We serve a veteran population of approximately 37,000 vets with

10 percent of those residing in the northwestern corner, Rio Blanco,

Moffat and Routt Counties of Colorado.

These numbers include Priority 8 group vets which are currently

not eligible for enrollment in VA health care if they are not already

enrolled.

17

This year we will actually see and provide health service to approximately 10,000 vets with about 700 of those residing in the

northwestern corner of Colorado. We at Grand Junction VA Medical Center are acutely aware of the access challenges, distance, geography, severe weather and hazards of wildlife. In a recent trip

up through the northwest corner I witnessed more antelope and

deer then I have seen in many years. So I appreciate the risks and

hazards there particularly at nighttime.

These challenges are exacerbated by the fact that we have a relatively small number of vets spread over a huge geographical area.

For example, in the northwest corner where we have 700 vets that

we are serving, they are spread out over 10,000 square miles. The

logistics of providing care for them are not inconsequential.

We agree that Veterans should not have to forego their VA

health benefits, which as Mr. Biro says very frequently, they have

earned, are entitled to and eligible for as a result of where they

live. Nobody asked them their ZIP code when they were drafted or

volunteered.

The challenge, however, is how do we provide that reasonably accessible care in a manner that is second to none in quality, which

VA, VISN 19 and Grand Junction have become known for, that is

at the same time cost effective and within current law, regulation

and policy, and within existing resources.

Grand Junction remains eager to discuss possible solutions to the

access issue which is so perplexing to yourself, to veterans, and, I

assure you, to those of us at the medical center as well. We stand

ready to work with all stakeholders to arrive at innovative, workable and supportable solutions.

This concludes my statement on behalf of the Grand Junction

VMC. Again, I would like to thank you for the opportunity to speak

on behalf of the Medical Center and the veterans that we serve

here on the Western Slope. Thank you.

[The prepared statement of Mr. Murphy follows:]

PREPARED STATEMENT OF MICHAEL W. MURPHY, DIRECTOR OF GRAND JUNCTION

VA MEDICAL CENTER

I would like to express my sincere appreciation for Senator Salazar’s interest and

concern for the veterans. We are privileged to serve and look forward to working

with him wherever possible to make improvements in our health care delivery.

Thank you for this opportunity to speak today on behalf of the Grand Junction VA

Medical Center (VAMC).

The Grand Junction VAMC is a part of the VA Rocky Mountain Network (VISN

19), which includes six facilities in Utah, Montana, Colorado and Wyoming. The facilities in Denver and Salt Lake City serve as tertiary referral hospitals for the

VISN.

The Grand Junction VAMC consists of one facility located in the city of Grand

Junction, Colorado, and one Community-Based Outpatient Clinic in Montrose, Colorado. The VAMC provides services to 37,000 veterans residing in 15 counties on the

Western Slope and two counties in southeastern Utah. The main patient building

was constructed during the period of 1947–1949. A Nursing Home Care Unit was

added in 1975 and currently functions as a 30-bed rehabilitative long-term care facility. A two-story outpatient clinical addition was completed in 1988.

The VAMC is a Complexity Level IV facility, which celebrated its 50th year of

service to veterans in 1999. It operates 53 beds comprised of 23 acute care and 30

Transitional Care Unit beds. The VAMC provides primary and secondary care including acute medical, surgical and psychiatric inpatient services, as well as a full

range of outpatient services. Specialized programs include a Mental Health Care

Center, substance abuse treatment, same day surgery, observation beds, computerVerDate 11-MAY-2000 13:20 May 04, 2006 Jkt 025787 PO 00000 Frm 00021 Fmt 6633 Sfmt 6621 C:\VA\25787.TXT CarolB PsN: CarolB
18

ized tomography (CT) and mobile MRI imaging. Patients requiring tertiary care are

transferred to Denver or Salt Lake City.

When necessary and appropriate, hospitalization and specialty care are provided

locally on a contract or fee for service basis. Through an agreement with local St.

Mary’s Hospital, the largest healthcare facility on the Western Slope, we obtain radiation therapy and other specialized medical services. The VAMC benefits from

scarce medical specialty agreements with community specialists who provide urology, ophthalmology, ENT, orthopedic, neurology and podiatry services. These agreements enable us to provide a spectrum of care and services, which far surpasses

comparably sized VA medical centers.

The VAMC was the recipient of the 2001 Presidential Award for Quality and the

1999 Robert W. Carey Quality Award Trophy. These achievements are especially

noteworthy because both were earned upon the first application. Of further note, it

is the first and only organization ever in VA to earn the Presidential Award for

Quality.

The Colorado counties in our patient service area (PSA) extend northward from

the medical center nearly 200 miles to the Wyoming border, southward approximately 150 miles to the northern borders of the counties of Montezuma, La Plata

and Archuleta and 190 miles east into the Rocky Mountains. Montezuma, La Plata

and Archuleta, formerly assigned to Grand Junction and VISN 19, were reassigned

to VISN 18 in the latter 1990’s. Grand Junction’s approximately 40,000 square mile

PSA is primarily rugged, isolated, mountainous terrain, made all the more difficult

in winter. We have continuously been aware of and managed our planning efforts

to include such considerations for veterans residing in the remotest reaches of our

PSA.

Also in the 1996–1997 timeframe, VISN 19 initiated a comprehensive strategic

planning process with all its VAMCs which resulted in a mutual decision with the

Grand Junction VAMC that we would prepare a business plan proposal for a community-based outpatient clinic (CBOC) in Montrose, Colorado. This decision, made

after reviewing other areas of our PSA, including northwest Colorado, was based

upon VA planning guidelines in place at that time that included thresholds for veteran population and projected users. Montrose was projected to serve a five-county

area comprised of Delta, Gunnison, Montrose, Ouray and San Miguel, in our southwestern PSA. A total of 8,045 veterans resided in this area at that time and has

since grown to 9,599. By comparison, total veteran population in northwest Colorado, comprised of the counties of Moffat, Rio Blanco and Routt, was 3,491 in 1996

and is currently 3,597.

Our Montrose CBOC proposal was ultimately approved by the Secretary of Veterans Affairs in 1998, endorsed by Congress, and the clinic opened in January 1999.

It has been successful to date, meeting the needs of underserved veterans in the

CBOC’s five-county service area.

During VHA’s national effort to realign existing resources with current and projected needs, known as the Capital Asset Realignment for Enhanced Services

(CARES) planning process, we participated with VISN 19 once again to conduct extensive strategic planning which included analysis of potential sites for CBOCs.

None were identified for the Western Slope based on current guidelines for veteran

population and the number of projected users.

VA CBOC planning guidelines, contained in VHA Handbook 1006.1, released in

2004, continue to emphasize need based upon veteran population, focusing in particular on the number of veterans, enrollees and actual users in the Priority 1–6

(P1–6) levels. Current P1–6 veteran data show northwest Colorado, comprised of

Moffat, Rio Blanco and Routt County, have low numbers overall that do not appear

to support development of a CBOC business plan. The dispersal of the veteran population, totaling 3,597, across approximately 10,325 square miles adds to the difficulty in achieving effective, efficient delivery of VA care.

Although the veteran numbers in northwest Colorado are low, demographics alone

are not the sole criteria. Other barriers including distance to existing VA care sites,

adverse weather conditions, hazardous roads and medically underserved areas must

also be factored into the decision process. Regardless, business plans, when submitted, ultimately require approval by the Secretary of Veterans Affairs based upon

a comprehensive assessment of how all planning criteria are met. The Grand Junction VAMC will continue to work with VISN 19 to develop proposals for CBOCs in

rural areas such as northwest Colorado so they can be evaluated and prioritized

within available resources.

In summary, we agree that veterans should not have to forego their benefits or

access as a function of where they live. The Grand Junction VAMC remains eager

to discuss possible alternative delivery methods that are within our resources and

within applicable VA regulations and guidelines.

19

This concludes my statement on behalf of the Grand Junction VAMC. Once again,

I thank Senator Salazar for his interest and concern for the welfare of our veterans

and their access to health care. I will be happy to answer any of your questions.

Senator SALAZAR. Thank you, Dr. Murphy. Thank you for the

great job you do with the Grand Junction Medical Center.

We will now hear from Cephus Allin who is a member of the

American Federation of Government Employees and who works at

the Ft. Collins outpatient clinic.

STATEMENT OF CEPHUS ALLIN, M.D., AFGE MEMBER AND

EMPLOYED AT THE FT. COLLINS VA OUTPATIENT CLINIC

Dr. ALLIN. Good morning. I am Dr. Cephus Allin. I am a member

of the American Federation of Government Workers, and for the

last year I have been the sole physician in the Ft. Collins CBOC.

I want to make it clear to the Committee——

Senator SALAZAR. Dr. Allin, can you——

Dr. ALLIN. Sure.

Senator Salazar [continuing]. Make sure the microphone is close

to your mouth as you speak so we can make sure that everybody

can hear in the back?

Dr. ALLIN. For the last 3 years I have been the sole physician

in the Ft. Collins CBOC. I want to make it clear to the Committee

that I am testifying here only on my own personal observations,

opinions and recommendations. I am not here before you to give

views of the Department of Veterans’ Affairs, as are Director Biro

and Dr. Murphy.

I would like to thank you personally for inviting me to testify

today. It’s a very rare honor and privilege for those of us who actually touch veterans to provide testimony to those who shape our

professional lives.

Ft. Collins can hardly be considered rural. It has 120,000 people

with upwards of a quarter-of-a-million in the catchment area. So

how would I qualify as a rural provider?

Ft. Collins has veterans who drive 150 miles one way to see me

because I am the closest VA provider. This is the reason we are

here, to project VA benefits out to rural locations.

I have three proposals: First, would be a meds proposal. Congress needs to enact legislation to allow non-VA physicians to write

prescriptions for our veterans using the VA formulary.

Second, would be to initiate sharing agreements, and this is different from privatization. But initiate sharing agreements with the

25 Colorado critical access hospitals.

And, third, to establish a strong central fee-basis program for

non-VA providers.

My first proposal on medications, there is considerable bargaining power in the VA formulary. This leverage drives medication costs down. Many veterans enroll in the VA solely to receive

these low-cost medications. Our veterans have more time than

money and will endure the waits and delays found at many facilities to avoid choosing between food and medication.

The VHA Directive 2002–074, the National Dual Care Policy, requires that a VA provider take an active role in patient management and documentation even after a qualified non-VA physician

has provided timely care.

20

The restrictions in Senate Bill 614 removes eligibilities for care

even as it extends it to prescription coverage. Dual care is a travesty when there is so many without any care. Please, please give

them their medications without limitations. They served without

limitations.

My second proposal is a sharing agreement. Again, this is not

privatization. Senator Salazar has taken a leadership position on

supporting our rural critical access hospitals. As part of a bipartisan effort, preserved Federal funding for our hospitals.

Critical access hospitals are, by definition, part of the rural communities. The map of those facilities was so compelling that it is

the first page in my written handout. Many of these hospitals already have staff who perform primary care and could function in

that capacity for our veterans. Many of them have an existing information technology infrastructure onto which the VA data structure might be projected.

We need sharing agreements as we have with the Department of

Defense. We need sharing agreements as we have with the Indian

Health Service. We need agreements in rural America so our Veterans’ Service Officers only have to arrange travel across town

rather than across the state.

The third proposal is a central fee-basis proposal. The March

2005 Office of the Inspector General report indicates the VA does

an excellent job of managing on-station, fee-basis funds. We should

expand this expertise into rural off-station services.

When a rural physician sees one of our veterans, they should be

able to send a bill to a central fee-basis office for payment. If payment were prompt and higher than the Medicare rate, the VA

would be considered an insurer of choice for rural providers.

We need as many CBOCs as you can possibly fund everywhere

in the State. Still, we won’t be able to project an appropriate

amount of bricks or mortar into rural communities. CBOCs are expensive, and the pressure on hospital directors to place them in

urban areas which will return the greatest number of new patients

is overwhelming. What we can project are care and caring into the

rural setting. We need to support non-VA providers who offer care

to our veterans by providing them a generous reimbursement. We

need to support the rural hospitals through which we will be able

to project our information infrastructure, and we need to support

our veterans by supplying the medications they need from providers near their home.

Again, I would thank you, Senator Salazar, for inviting me here

to present my own views, and I would be happy to answer any

questions.

[The prepared statement of Mr. Allin follows:]

PREPARED STATEMENT OF CEPHUS ALLIN, M.D., AFGE MEMBER AND EMPLOYED

AT THE FT. COLLINS VA OUTPATIENT CLINIC

Good morning, I am Dr. Cephus Allin. I am a member of the American Federation

of Government Workers. For the last 3 years I have been the sole physician in the

Fort Collins CBOC.

I would like to personally thank Senator Salazar for inviting me to testify today.

It is a rare honor and privilege for those who actually treat veterans to provide testimony to those who shape our professional lives.

Fort Collins can hardly be considered rural: 120,000 in the city with upwards of

a quarter of a million in the catchments area. So how do I qualify as a rural proVerDate 11-MAY-2000 13:20 May 04, 2006 Jkt 025787 PO 00000 Frm 00024 Fmt 6633 Sfmt 6621 C:\VA\25787.TXT CarolB PsN: CarolB
21

vider? I have veterans who drive 150 miles to see me, because I am the closest VA

provider.

This is the reason we are here today. To project VA benefits out to our rural veterans.

I have three proposals:

(1) Congress needs to revise Public Law to allow Non-VA Physicians access to the

VA formulary for our veterans. The MEDS ONLY proposal.

(2) Initiate sharing agreements with the 25 Colorado Critical Access Hospitals.

The Sharing Agreement proposal.

(3) Establish a strong Fee Basis program for Non-VA providers. The Fee Basis

proposal.

PROPOSAL ONE: MEDS ONLY

There is considerable bargaining power in the combined DoD/VA formulary. This

leverage drives medications costs down and many veterans enroll with the VA solely

to receive these low-cost medications.

Many of our veterans have more time than money and will endure the waits and

delays found at some VA facilities to avoid choosing between food and medications.

VHA Directive 2002–074: VHA National Dual Care Policy requires that a VA provider take an active role in patient management and documentation even after a

qualified Non-physician has already delivered timely care. Dual care is a travesty

when so many are without any care.

PROPOSAL TWO: SHARING AGREEMENT

Senator Salazar has taken a leadership position on preserving the rural Critical

Access Hospitals and as part of a bipartisan effort preserved Federal funding for

these rural hospitals.

Critical Access Hospitals are by definition part of rural communities. The map of

those facilities is so compelling that it is the first page in the handout.

Many of these hospitals already have staff who perform primary care and could

function in that capacity for us. Many of them have an existing Information Technology infrastructure onto which the VA infrastructure might project.

We need sharing agreements, as we have with Department of Defense, we need

sharing agreements as we have with Indian Health Service. We need rural sharing

agreements so our VSO’s have only to arrange travel across town rather than across

the state.

PROPOSAL THREE: FEE BASIS

The March 2005 Office of the Inspector General report indicates that the VA does

an excellent job of managing on-station Fee Basis. We should expand this expertise

into rural, off-station services. When a rural physician sees one of our veterans, they

should be able to send the bill to a Central Fee Basis Office for payment. If payment

was prompt and, perhaps double the Medicare rate, veterans would immediately become the preferred patrons in rural practice.

We won’t be able to project a significant amount of bricks, mortar or staff into

rural communities. CBOCs are expensive and the pressure on Hospital Directors to

place them in areas which will return the greatest number of new patients is almost

overwhelming. About 11 percent of our CBOCs are in counties designated as rural

(fewer than 100 people per square mile).

What we can project are care and caring into the rural setting. We need to support Non-VA providers who offer care to our veterans by providing them a generous

reimbursement; we need to support the rural hospitals through which we will be

able to project our information infrastructure and we need to support our veterans

by supplying the medications they need from providers near their homes.

Again, I would like to thank Senator Salazar for inviting me to this forum and

I would be happy to answer any questions.

Senator SALAZAR. Thank you very much, Dr. Allin and members

of the panel for your testimony this morning. I know you have also

submitted written comments that we will make a part of the record

here this morning.

I am going to ask a number of questions. In the interest of time,

I am going to ask the panel to respond to them. Some of them are

specifically addressed to a couple of you.

22

The first question is to Director Biro, and that is the decision of

the Veterans Health Administration and VISN 19 not to place a

clinic in northwest Colorado. We heard Mr. Condie talk about the

empty quarter in northwest Colorado. When I look at the map of

Colorado that shows the different CBOCs that we have in this

State, the different facilities, it seems to me we have two rural

quarters that are uncertain. We have northwest Colorado, and we

also have the northeastern part of our State. I know that in your

testimony you talked about the fact that we still had not completed

the recommendations of CBOC as set forth in the CARES Commission recommendations.

My question to you is: How can we move forward in an expedited

manner to ensure that we do have a CBOC in northwest Colorado

as well as northeast Colorado? How can I as a Senator, how can

the Veterans’ Affairs Committee, help you address that issue into

the future?

So write that one down for a second, because I am going to try

to go through all of my questions before we have the panel members respond.

As part of that question also, Director Biro, the criteria that are

used now for the decisions that are made with respect to the location of the CBOCs, they don’t seem to be consistent to me in terms

of where the CBOCs are being placed. Is there something that we

can do to help clarify that criteria from a legislative point of view?

Second, Dr. Biro and Dr. Murphy, if you would also just address

the budgetary issues with respect to VA’s health care as it relates

to rural areas. Dr. Murphy, you in particular here on the ground

in Grand Junction—too much energy behind those microphones—

the budgetary issue that we see in terms of serving vets who live

far away from Grand Junction, for example, in northwest Colorado,

how you see us addressing those budgetary issues.

Mr. Riedinger and Mr. Condie, you both live the reality every

day of having to go out and raise money and work with the dealerships to provide the transportation services so that our veterans do

have access. I would like for you to comment on how a creation of

a CBOC, Mr. Condie, up in northwest Colorado, might be helpful

to the efforts of serving veterans there. Also if you would talk just

about the financial challenges that we have in terms of providing

transportation.

On fee-based care, you heard both Dr. Murphy and Dr. Allin, Director Biro and their comments. So, Dr. Biro, I would like you to

respond to their testimony with respect to fee-based care and how

we as a Nation can move forward to address some of the concepts

and proposals that Dr. Allin and Dr. Murphy talked about.

I have heard your testimony on tele-medicine. I will withhold my

question there. I guess, the financial question I would have would

be on Native American veterans. We have hundreds of thousands

of Native American veterans from all wars that have provided a

great service to our country. I know in the next battle we are going

to hear some issue there specific to Native Americans.

So with that, I would ask you to keep your responses to all those

questions relatively short. So why don’t we start with you, Director

Biro, since most of those questions were directed to you, I will give

you 5 minutes, and then I will give the other members of the panel

23

2 minutes a piece to respond to whatever they want with respect

to those questions or any of the testimony that you have heard

here this morning.

Director Biro.

Mr. BIRO. Getting a CBOC in northwest Colorado: Basically, as

I outlined, it’s a question of resources and priorities. The way I set

the priorities, it seemed as reasonable as I could, is that we could

take care of capital asset realignment for enhanced services first.

That seemed to be—something that was concrete I could do and I

could lay out.

After that the rest, and I would say somewhere between 15 and

20, we really don’t have priorities for. Maybe one in every location,

geographical location, might be a way to do that. It was kind of a

Maslovian thing that, you know, we were doing those three promises. I had no money to do a CBOC, so, very frankly, I didn’t work

on the priorities. That made sense. I could do that.

Moving ahead, the things that you have done. It’s no secret, what

you have said, rural areas are neglected. There is no office, a central office, for rural health. There is no advocacy among the previous representative in this area. Mr. McGinnis introduced this legislation a couple of years ago. We discussed this briefly with the

leadership of VA, which is basically gone now, that the rural area

is not represented. It is an urban focus or a suburban focus, and

that’s something that needs to be looked at. That’s something certainly your committee could do. Give some clear direction to our

board of directors to say we want some additional attention to the

rural situation.

Everything you said, rural veterans are sicker, it is worse to live

out in the country than it is to live in, wherever, downtown Denver

or downtown Salt Lake. So that’s the issue.

So moving ahead to northwest Colorado and how you can help

would be all the good things that you have done already. 2006 is

going to be better than 2005. If we are going to have money to do

that, we need to keep that going forward to have that money. To

focus that money on rural projects is the right thing to do. That

would be one way of getting somebody’s attention. So those would

be my two suggestions to move it ahead. Either way, a nonmonetary of having something and the authorization saying you need to

develop—have an office for rural health, and you need to put that

in the plan one way or another, get a report on that.

The criteria—I don’t know about the placement. The criteria is

what I said. You will have problems doing virtually every community-based outpatient clinic in VISN 19 because we don’t have the

population. We scored the northwest clinic. It has a score card in

the back of policy directive, and we don’t make it. It would require

some sort of waiver to do northwest Colorado or virtually every one

of the ones that we have.

Now, are they amenable to changing that? Sure. Have we worked

on it? Not really, but since again funds were tight there were not

CBOCs going on, we didn’t take that up. But we certainly should

take that up. So the criteria is biased toward—let’s say toward

urban areas and toward networks that have a lot of money. Because you have to certify. You cannot break those facilities.

24

Budgetary issues, historic. 2005 was a tight year. We got about

a 4 percent increase. VISN 19 gets its fair share of funds. I use a

simple formula, and I advocate for veterans within the Veterans

Health Administration and VISN 19 all the time. We are 2.5 percent to the veteran population. We would expect that we would get

2.5 percent of any appropriation, any special money, any money

that comes out that we need to get 2.5 percent. We have certainly

gotten that 2.5 percent and more.

So we recognize our growth, which is about the second biggest

in the VHA and the VERA process, our equitable distribution process. Any process to send funds to the field has been recognized.

But 4 percent is a tight, very tight, budget. Our cost per delivery

of care went up 3 percent alone. So that left us 1 percent per capita. So that left about 1 percent to do anything else. So funds were

tight, but we delivered.

I would like to say that you have not heard any horror stories

in 19. I met my promises. Dr. Murphy has met those promises over

and over again. We will do everything in our power to deliver to

veterans the care that they have earned, deserved and are entitled

to. I wouldn’t be testifying if I can’t do that. You will have somebody else here, because I will not—I cannot do the job if I can’t do

the job.

Senator SALAZAR. Will you comment briefly on the fee for services proposal?

Mr. BIRO. Right. The fee basis, just very quickly, Title 38, the

law is very prescriptive in fee basis. It’s reserved primarily—or not

primarily—for service-connected veterans. It’s in the law. I have

got the law here, and it’s very clear that you have to be service connected to get fee basis. It’s very tightly controlled. The last element, and it’s an ‘‘and’’, is inability to get services in a particular

area.

So the way fee basis is used, the way the directives are, is primarily to take care of service-connected veterans. It is very tightly

controlled. That’s all I can say. We have an office that does that.

There may be some inconsistency where other people are using it

to take care of other-than-nonservice-connected veterans. I can’t address that.

Then closing with Native Americans, I am very proud of the

VISN 19 program. We have what’s called tribal veterans representatives from every tribe in our area. They reach out to veterans.

I am very proud of our PTSD program that is, again, a very personalized program. We have tribal outreach workers who go out

and look for veterans who have PTSD and any problem as far as

that’s concerned.

I know the representative from the North Ute Tribe is going to

speak to you. We are in the process of doing an MOU with the Indian Health Services in the service area for the Northern Ute

Tribe.

We have a full-time outreach person, Mr. Richardson, who is out

somewhere right now in his pickup truck and is out in those four

states working those veteran issues. I am in constant contact with

the tribes and their tribal councils and presidents of the tribes, and

we endeavor to reach out to them. We have a very culturally sensitive program. We have Native American healers. Actually, in RivVerDate 11-MAY-2000 13:20 May 04, 2006 Jkt 025787 PO 00000 Frm 00028 Fmt 6633 Sfmt 6601 C:\VA\25787.TXT CarolB PsN: CarolB
25

erton, Wyoming we have a sweat lodge on our property, so we do

whatever is necessary. That goes down to every veteran will be personally satisfied.

Senator SALAZAR. Thank you, Director Biro. In the interest of

time I will have each of the panelists, if you wish, to go ahead and

give us a 2-minute comment on the questions I asked for the points

that were made by Director Biro. Why don’t we start with you, Dr.

Murphy and then Dr. Allin.

Dr. MURPHY. Grand Junction has been rather fortunate in its

funding level and has basically had adequate funding to do our

business as usual. We haven’t had the funding to expand and develop new areas of activity, but we have done well. It’s not only a

quality organization, it’s been a highly efficient organization for

several years certainly preceding my arrival here a few months

ago.

We do have some outreach in the form of tele-health. We have

health buddies that go into the home to monitor patients, as you

talked about, with blood pressure, chronic obstructive pulmonary

disease, and hypertension. We are beginning very shortly to have

tele-psychiatry which will operate between our home base here in

Grand Junction and the CBOC in Montrose where patients can

come in, we will have the tele-health equipment there, and we can

do tele-psychiatry there. We are doing some tele-work where it involves going from facility to facility. Some you can do from home

to facility, others of it is health care facility to health care facility.

We are getting involved in both.

We have been able to expand our medical staff to support some

of the beyond-primary-care activities that I mentioned, and neuroorthopaedic surgery is an example of that. That’s a very expensive

program to run, and, yet, we have been able to support that with

funds that VISN 19 has provided. I think that’s an excellent service

considering that we represent the VA for 180 miles toward Denver

and probably that far toward Salt Lake all the way to——

Senator SALAZAR. Would a CBOC in northwest Colorado help?

Dr. MURPHY. It probably would. We are challenged by the VA’s

criteria at the moment.

Senator SALAZAR. But if we were to change the criteria and figure out a way of putting a CBOC up there, it would help in connection with health care delivery services including tele-medicine?

Dr. MURPHY. We might have a base to have some tele-health out

there in a CBOC. I mean, all things are possible with money,

so——

Senator SALAZAR. Got to get the numbers, right?

Dr. MURPHY. Yeah, get to the numbers. I would mention something on your VetsRide bill. Grand Junction tried a number of

years ago with its own funds to set up a bus transportation system

where a bus from here was contracted and made the route up to

Routt County and back. It was discontinued for low ridership. On

some days we actually had almost zero to zero vets riding it.

I think the plan that your legislation proposes, where the rides

would emanate from the counties, probably would be more effective

in trying to manage it on our end. So I think that the approach

that your bill has to offer probably is an extension beyond what we

were not able to do successfully, just because the ride was too long

26

to vets. It was just too much of a day. If it emanates from there,

I think it might work better.

Senator SALAZAR. Thank you Dr. Murphy.

Dr. Allin.

Dr. ALLIN. I believe, along with Director Biro, that the VA provides care second to none. The CBOCs, a staffed CBOC, is the first

best option for that care anywhere, rural, suburban or urban care,

the VA and its providers do the best job.

That being said, there are going to be some areas where it will

be impossible to put brick and mortar. In that area there are veterans who have earned the right to care from the VA. There must

be other ways to provide them with local care.

If you can fund CBOCs, I would say absolutely with employed

staff. If you cannot fund that, then place in the very rural areas,

one to six civilians per square mile, the ability to provide our veterans with some help.

Senator SALAZAR. Thank you, Dr. Allin.

Mr. Riedinger.

Mr. RIEDINGER. What I have experienced with the transportation

program is it’s gone from difficult to almost suppressive. We have

two vehicles. There is a Colorado trust fund which makes it easy

to get a vehicle. The hard part is maintaining a volunteer program.

Our trips to Albuquerque can be as long as 16-hour days. Sometimes, I mentioned before, veterans hospitals will say, ‘‘Well, we

can’t complete your exams today. You need to stay over.’’ So then

there is an accommodation problem, because there are no accommodations except for, I believe, radiation treatments for cancer.

I went from 22 prospective drivers to one that stuck it out

through the process. Even the qualification process that’s imposed

by the medical center, it’s a laborious process, and it’s a turnoff to

volunteers.

Senator SALAZAR. So your suggestion, then, would be to take a

look at the per-diem reimbursement that we currently provide for

vets that have to take these rides to seek health care in places that

are at some distance?

Mr. RIEDINGER. A lot of this is the paperwork. There were some

fatalities within the system, so they are paying attention to the

medical health of the driver. What has happened is they are constantly adding what it takes to qualify. It takes a long time and

requires a trip to Albuquerque to be qualified to begin with.

Senator SALAZAR. Thank you, Mr. Riedinger and Mr. Condie, for

your concluding comments?

Mr. CONDIE. Yes, sir. The transportation issue out starting in

Steamboat Springs and going through Hayden and going through

Craig and going through Meeker is normally done on a demand

basis. They call me or they call the VSO in Craig who is the representative of Moffat County. We can get the veterans down to the

hospital. All we need is time to do that.

I have five drivers I select from to break up driving on one individual. I do provide the vehicles, new vehicles, air conditioned vehicles. The idea of purchasing a vehicle is not practical. You have to

find someplace to park it, you have to find somebody to maintain

it, and you have to find somebody to insure it. It’s not practical.

27

So the process which I do I found practical. I have been doing

it for 4 years. I will continue to do it to provide transportation for

veterans starting at Steamboat Springs to Grand Junction. I provide transportation through the Alpine Taxi service that starts in

Steamboat to Denver. I buy a round-trip ticket for the veteran.

There is no public transportation in our region, none at all. So

the thing here is, if myself or other folks like me don’t make the

effort, nothing gets done. Having a CBOC or having a partnership

with one of the hospitals on Route 40 would work out best for the

veterans in that region.

The veterans in that region encompass over 14,000 square miles,

and the thing here is that’s Jackson, Grand, Routt, Moffat, Rio

Blanco, northern parts of Garfield County. The thing is there is no

place for these vets to go except to have to travel. That’s the best

I can say, sir.

Senator SALAZAR. Thank you very much, Mr. Condie, and to all

the members of the panel for the time you have taken to appear

here before us and for the testimony that you have provided.

We will take about a 3-minute break while we get the other

panel to come forward, and then we will resume the hearing in

about 4 minutes. Thanks very much.

[Recess.]

Senator SALAZAR. Why don’t we go ahead and resume the hearing. We are going to hear from our second panel today, and I would

like to welcome Charlie Watkins who is the Colorado Department

Chief of Staff for the VFW. He lives in Craig Colorado, and I had

the honor of meeting with him up there just last night.

Jim Stanko, an Army veteran who has been home for, it seems,

forever and has been a strong advocate for the veterans’ issues we

are talking about in northwest Colorado.

George Leonard, a World War II Navy veteran who has been active in the Durango veterans community for many years.

Howard Richards, former chairman of the Southern Ute Indian

Tribe and a great leader in our State and a Vietnam veteran.

Thank you for being here.

Paula Rothman who came here to Grand Junction after having

served in the Army during the first Gulf war. Thank you for being

here.

Hank Stroncek, a World War II veteran with the Coast Guard

and who currently lives in Steamboat Springs.

Leonard Yoast is 85 and doesn’t look it, looks much younger. He’s

a World War II veteran from Hayden, Colorado.

And Michael Adams, a physician’s assistant from Iraq who now

works as a health care professional in Norwood.

Thank you all for your service, and thank you for being here

today. Because of the number of panelists that we have, I am going

to ask you if you can limit your comments down to about 4 minutes. We have received your written testimony, and that testimony

will become a part of the record.

So with that why don’t we start with Charlie Watkins and take

testimony from him.

28

STATEMENT OF CHARLES WATKINS, VETERANS OF FOREIGN

WARS, COLORADO DEPARTMENT CHIEF OF STAFF, CRAIG, CO

Mr. WATKINS. Good morning, Senator. I would like to take this

opportunity to thank you for all you are doing for our veterans to

right the tragic wrongs of our government in the Veterans’ Administration.

I strongly believe that the Veterans’ Affairs Administration has

been severely lacking in leadership at the medical center and regional office level for many years. Many of the employees have lost

sight of the mission of the Veterans’ Affairs, which is to care for

our veterans. They feel the VA exists just so they can have a job.

The VA and the government have created many artificial roadblocks’ rules over the years that have hindered and precluded the

health care of our veterans. No one told us when we went off to

war if we came home and became successful later in life we would

lose our health care. They have changed the rules obtaining health

care so many times that it is difficult even for an attorney to decipher if you qualify and what you must do to receive your health

care. The means test is a typical example. If you don’t see a doctor

in the VA facility for 2 years, once again, care is denied. If you go

to the emergency room at a local hospital, your bills will not be

paid.

These are just a few of the arbitrary rules of the VA.

Their rules even become more arbitrary in deciding service conductibility and what percent you should receive. The VA never reevaluates their medical retirees, but every veteran who is drawing

disability will be re-evaluated every 2 to 3 years. We need to eliminate these arbitrary rules.

Several years ago when the VA closed the VA Medical Center at

Ft. Lyon, Colorado, they put in a CBOC in Lamar, La Junta, Pueblo, Alamosa, Durango, and Montrose which is 60 miles from one of

the No. 1 VA hospitals in the nation. Now they are thinking that

they need a CBOC in Rifle. Once again, that’s 60 miles away. We

need a CBOC in northwest Colorado.

In northwest Colorado we are greatly concerned about the health

care of our aging veterans. Our counties are spending a great deal

of money annually to transport veterans to the nearest VA facility.

Many of our elderly veterans cannot drive and many have no family to transport them. They are required to travel up to 300- to 500-

mile round trip just to get their health care, which can take 3 to

5 hours over windy mountain roads. During winter months the

time can be significantly increased because of bad weather, open

range cattle, and deer and elk migrations which endanger their

safe travel to the VA.

The long distance to the VA to obtain needed health care is taking its toll on many of our veterans. It is almost counterproductive

because of the length of travel to the VA. Many veterans require

several days just to recover from the trip. Although there is funding for local care, it is extremely difficult to get approval, and I

don’t know of a single request that we have submitted that has

been approved.

The veterans of northwest Colorado served their country honorably and they deserve the same consideration for health care that

29

is given to veterans in other parts of the country. A CBOC in our

area would aid significantly in the health care of our veterans.

I shutter to think that this country is not willing to uphold its

responsibility to care for our veterans who made many sacrifices to

ensure the security and freedom this country and many others

enjoy. Our government thinks nothing of putting soldiers in harm’s

way to protect the rights of others. We spend hundreds of millions

of dollars annually to aid and prop up foreign countries around the

world. Charity should start at home caring for our veterans.

At times, I think we should give every soldier a Medicare card

when he gets out of the service and let him get his health care

where he lives, and we could shut down many of the VA facilities

saving millions of dollars. Medicare may not be the answer, but it

seems to work.

Our government over the years has promised our soldiers they

would be taken care. The veterans have fulfilled their obligation to

the country. It is now time for our country to fulfill its obligation

to our veterans. In this country today we take better care of criminals who are incarcerated than we do honorably discharged veterans.

There is a famous quote by Calvin Coolidge that reads, ‘‘The Nation which forgets its defenders will itself be forgotten.’’ We are seeing evidence of that today as our recruiters are not meeting their

quotas. The youth of this country are ours. They are very bright.

They see the country as not taking care of us. Why should it take

care of them? Knowing full well they will not be taken care of, they

are not willing to serve.

If we are asking a soldier to stand in harm’s way, we assume a

responsibility to care for him in his time of need.

We, of northwest Colorado, want to ensure our veterans receive

the health care they deserve and that it is timely. It should be second to none, and it should be relatively convenient. Nowhere else

in the State are veterans required to travel so far or endure so

much to receive the health care that they so rightfully deserve.

Thank you, sir, for allowing me to testify today.

[The prepared statement of Mr. Watkins follows:]

PREPARED STATEMENT OF CHARLES WATKINS, VETERANS OF FOREIGN WARS,

COLORADO DEPARTMENT CHIEF OF STAFF, CRAIG, CO

Good morning Senator Salazar. I would like to take this opportunity to thank you

for all you are doing to help our veterans and right the tragic wrongs of our government and the Veterans Affairs Administration. I strongly believe that the Veterans

Affairs Administration has been severely lacking in leadership at the Medical Center and Regional Office level for many years. Many of the employees have lost sight

of the mission of the Veterans Affairs, which is to care for our veterans. They feel

the VA exists just so they can have a job.

The VA and the government have created many artificial roadblocks and rules

over the years that hinder and preclude the health care of our veterans. No one told

us when we went off to war that if we became successful later in life we would lose

our health care. They have changed the rules for obtaining health care so many

times that it is difficult even for an attorney to decipher if you qualify and what

you must do to receive your health care. The means test is a typical example. If

you don’t see a Doctor in a VA facility for 2 years, once again your care is denied,

if you go to the emergency room at a local hospital your bills will not be paid. These

are just a few of the arbitrary rules of the VA. Their rules even become more arbitrary in deciding service-connected injuries and what percentage you should receive.

The VA never re-evaluates their medical retirees, but every veteran will be re-evaluVerDate 11-MAY-2000 13:20 May 04, 2006 Jkt 025787 PO 00000 Frm 00033 Fmt 6633 Sfmt 6621 C:\VA\25787.TXT CarolB PsN: CarolB
30

ated every 2 to 3 years to reduce their disability. We need to eliminate these arbitrary rules.

Several years ago when the VA closed the VA Medical Center at Fort Lyon, CO

they put in a CBOC in Lamar, La Junta, Pueblo, Alamosa, Durango, and Montrose,

which is only 60 miles from the VA Hospital in Grand Junction. Now they think

they need a CBOC in Rifle, once again it is 60 miles from Grand Junction. There

was no consideration given to northwest or northeast Colorado to provide health

care for those veterans. It is time we rectify this situation and put a CBOC in NW

Colorado.

In NW Colorado we are greatly concerned about the health care of our aging veterans. Our counties are spending a great deal of money annually to transport veterans to the nearest VA. Many of our elderly veterans cannot drive and many have

no family to transport them to their appointments. Our veterans are required to

travel 300–500 miles round trip just to get their health care, which can take 3–5

hours one way over winding mountain roads. During winter months the time can

be significantly increased because of bad weather, open range cattle and deer and

elk migrations, which endanger their safe travel to the VA.

The long distance to the VA to obtain needed health care is taking its toll on

many of our veterans and it is almost counter productive. Because of the length of

travel to the VA many veterans require several days just to recover from the trip.

Although there is funding for local care, it is extremely difficult to get approval and

I don’t know of a single request that has been approved. The veterans of NW CO

served their country honorably and they deserve the same consideration for health

care that is given to veterans in other parts of the country. A CBOC in our area

would aid significantly in the health care of our veterans and particularly our aging

veterans.

I shutter to think that this country is not willing to uphold its responsibility to

care for our veterans who made many sacrifices to ensure the security and freedom

this country and many others enjoy. Our government thinks nothing of putting soldiers in harms way to protect the rights of others. We spend hundreds of millions

of dollars annually to aid and prop up foreign countries around the world. Charity

should start at home by caring for our veterans. At times I think we should give

every soldier a Medicare card when he gets out of the service and let him get his

health care where he lives and we could shut down many of our VA facilities saving

millions of dollars. Medicare may not be the best possible care, but it seems to work.

Our government, over the years promised our soldiers they would be taken care

of. The veterans have fulfilled their obligation to our country and it is now time for

our country to fulfill its obligation to our veterans. In this country today we take

better care of criminals who are incarcerated than we do our honorably discharged

veterans. There is a famous Calvin Coolidge quote which reads: ‘‘The Nation which

forgets its defenders will itself be forgotten.’’ We are seeing evidence of this today,

as our recruiters are not meeting their quotas. The youth of this country are ours.

They are very bright and they see that the government has lied to us in the past

and we have not been taken care of. They are not willing to serve this country,

knowing full well they will never be taken care of either. If we ask a soldier to stand

in harms way we assume a responsibility to take care of him in his time of need.

We in NW CO want to ensure our veterans receive the health care they deserve

and that it is timely. It should be second to none and it should be relatively convenient. Nowhere else in the State are veterans required to travel so far or endure so

much to receive their health care. We value our veterans and their contributions

to this country and we would greatly appreciate your assistance in obtaining a

CBOC in NW CO to serve our veterans.

Thank you Senator Salazar for allowing me to testify today.

Senator SALAZAR. Thank you very much, Mr. Watkins.

AUDIENCE. Can our president get involved in it?

Senator SALAZAR. We will hear from the panelists, and, again, for

anyone here who wants to provide us with comments and testimony, we have forms. If you will provide us that testimony, we will

make sure that it is included as part of the record for the Senate

Veterans’ Affairs Committee.

Mr. Stanko.

31

STATEMENT OF JAMES W. STANKO, AMERICAN LEGION

DISTRICT 14 COMMANDER, STEAMBOAT SPRINGS

Mr. STANKO. Yes, thank you, again, Senator Salazar, for allowing

us to come down and speak.

I think basically what I would like to address is some of the

things that were touched on even in the earlier panel is that veterans health care, even though it’s an issue that concerns us in

northwest Colorado, is just the tip of an iceberg of really a health

care issue across the United States. It shows that our health care

is in a critical condition.

This is what is placing a stress on the veterans is the fact that—

or on the VA is the fact that a lot of people are losing their health

care and are having to turn to the VA to receive health care. It’s

not going to get any better, because as more young men and

women and the people who are serving come out, they are going

to need health care. If they can’t afford it through insurance and

certain things like this, they are going to keep turning to the veterans’ health care.

A statistic that was just brought out that really kind of amazed

me is that I heard this figure: 700,000 veterans in Region 19 of the

CARES, but only 146,000 or 150,000 of them are in the system.

But that doubled since 1996. Well, if it doubled in the 5 years or

4 years or 10 years, it’s going to double and triple in the next few

years.

I think the real solution that we need to look at is that we need

to look at reforming what was already some of the programs within

the VA itself. If this Title 38 is a hindrance to getting local health

care, that’s something that I think we need to look at and take care

of.

I am extremely concerned when we talk about going to CBOCs

and building brick and mortar, because I don’t think this is the

way to go. I think the way to go is a contract service. Even the VA

hospital here in Grand Junction, they just said they contract out

to St. Mary’s. They have to contract some of their services.

Wouldn’t it make more sense to start contracting services in local

communities where veterans can go to their own doctors, doctors

that they are familiar with, in surroundings that they are familiar

with, and come up with some sort of a fee-based system or some

sort of a system using Medicaid, using Medicare, getting it all combined into one thing? As was mentioned by one gentleman where

you could have your VA medical card, go to any facility, you can

get the medical care that you need. You can present that card to

that hospital. That group can then bill one entity, like the VA,

which could also get some added money and stuff from Medicaid

and Medicare.

I think keeping the CBOCs or keeping contract services locally

is great, too, because it keeps local tax dollars local. We all pay

Federal income tax. This is some way to keep some of that local

tax money back into the local hospitals.

By also having local veterans come to local hospitals, it also

builds the patient base for that hospital so that they can get better

funding and grants or have better care and services because they

have a bigger base.

32

The three hospitals in northwest Colorado all seem to agree that

this is the thing that they would like to do. I have letters and resolutions from each of the three hospitals, the Kremmling Memorial

Hospital District, the Yampa Valley Medical Center and the Memorial Hospital in Craig. They are all addressed to you, Senator. I am

going to present them to your aide here. I would like for you to

read them. But in each of these letters these hospitals are willing

to work with the VA to provide health care.

I think this can be accomplished, not only in Colorado, but in all

of those rural states in CARES 19, but it’s going to take some

changing of the rules. That’s what I think we need to start here

in northwest Colorado. This hearing today is—northwest Colorado

wants to be the leader, not only in getting CBOC or health care,

but in starting to change the rules to make the VA more effective

to serve what they are supposed to serve, the veterans of the

United States.

[The prepared statement of Mr. Stanko follows:]

PREPARED STATEMENT OF JAMES W. STANKO, AMERICAN LEGION DISTRICT 14

COMMANDER, STEAMBOAT SPRINGS

Thank you for allowing me to present testimony on veterans’ health care. I would

like to take this opportunity to address some issues which are of importance to veterans of Northwest Colorado and through out all rural areas of Colorado.

Health care is becoming a national issue with the cost of insurance becoming a

financial burden to many families. Employers are looking to cut benefits as a way

to reduce costs and many veterans, especially those in their late 50s and early 60s,

are getting caught up in this loss of benefits; therefore, they are turning to the VA

as a means of having some form of health insurance. This is putting a strain on

the Veterans’ Administration.

This is a problem that will not go away. There is a steady growth of men and

women who have served their country reaching an age where they will be looking

to the VA for heath care. We also have those that are currently serving; these service members will be coming into the system in just a few years. The VA health care

system needs some serious overhauling in order to accommodate these future veterans. The time to start this is now and one of the places we can start is here in

Northwest Colorado.

Northwest Colorado is one of the few areas of the State that Veterans have to

drive more than 180 miles to reach a VA health care facility. Because we are in

a very mountainous area, a trip to a VA facility can become a dangerous adventure.

Weather conditions and dodging game animals on the road is something our older

World War II and Korean War veterans should not have to do. Many of the Viet

Nam era veterans are also in or approaching their sixties and driving for them can

also be difficult.

The solution that American Legion members of our Post, along with members of

other Posts in the District, would like to suggest is to establish VA health care contracts with local medical facilities for basic healthcare. A contract with local medical

facilities would accomplish several things. First, it allows veterans to get basic

healthcare in a facility they are familiar with and with medical personnel they

know, trust, and are comfortable with all without the stress of travel. Second, this

allows tax-payer dollars to remain local. Third, it would generate more patient activity for the local hospital which would help with hospital income. This solution would

save resources, the local hospital’s already exist; no new facilities would need to be

built, equipped, and staffed. This would save the Veterans’ Administration financial

resources. Veterans’ would be working with healthcare givers who are already familiar with their medical history, thus saving time resources (no review of medical history needed), medical testing (the local doctor knows which tests have been done,

thus, no duplication of testing), and with minimal traveling, the veteran would save

serious money on fuel costs. It is a solution which will help at both the local, state,

and national levels.

Two American Legion members of our Post, Gar Williams, a Department of Colorado Jr. Vice Commander, and Mike Condie, the County Veterans Affairs Officer,

have been working hard on getting local medical facilities to come on board with

this idea. To this end, I am able to present a letter from the Yampa Valley Medical

33

Center in Steamboat Springs and a Resolution from the Kremmling Memorial Hospital District affirming that they would be willing to work with the VA to provide

services to veterans. The Craig Memorial Hospital has also indicated they would

work with the VA. These documents show that there is a willingness of the medical

facilities in Northwest Colorado to work with the VA to come up with a contract

that would benefit Veterans at the local level.

This contract system would not only benefit Northwest Colorado, but would also

help rural communities in the other three remote corners of the State. Contracting

for health care is not a new idea for the VA. In fact it already happens in many

rural areas in other States. As an example, in Western Nebraska, the VA employs

practicing nurses to visit and care for veterans.

Another alternative is to actually get a Community-Based Outpatient Clinic in

Northwest Colorado. Steamboat Springs has been suggested as the site for this clinic because it is central to all Counties involved. However, as I have pointed out, this

is a duplication of services. A CBOC would have to contract space, and equipment,

mostly likely from the local hospital. Also the Visiting Nurses of Northwest Colorado

are trying To get a clinic for the care of seniors and the community of Oak Creek

is trying to find a way to fund their clinic, so why another clinic? Money used to

fund a clinic that duplicates services could be better used to contract services for

veterans. But if a CBOC is the only alternative the VA has to offer the Veterans

of Northwest Colorado, then we’ll take it.

I would also like to take this opportunity to support your bill, The VetsRide Act

S. 1191. This is a very positive step in helping veterans in rural areas. As a veteran’s organization we are very pleased with the amendment on Community-Based

Outpatient Clinics. Also, if Northwest Colorado does not end up with health care

contracts or a CBOC, the transportation grants would be a tremendous asset in

solving the funding problems we have in getting veterans to a VA hospital.

I would like to encourage Senator Salazar to join with the American Legion position in supporting mandatory funding for the VA, especially VA healthcare. This is

the real solution to the health care funding problem. Even though the current Administration claims an increase in VA funding, this funding is woefully inadequate.

Men and women that have served or are currently serving deserve and have earned

the right to reasonable health care and our Government needs to accept this responsibility and step forward with mandatory funding.

I, along with many veterans that did not serve in a combat zone or situation are

very concerned with the Administration’s position to create a ‘‘core constituency’’

will place undue financial burdens on the class 7 and 8 veterans. Every person that

has put on a military uniform has made a sacrifice. They have left their homes,

loved ones and friends to defend in some way their country and the liberties and

freedoms of all Americans; and now a majority is being told they are not really veterans. The Veterans Committee needs to be made aware of the fact that it takes

10 to 12 or even more military personnel to support each combat soldier. When you

put on a military uniform you become part of the United States Military and your

job is to preserve, protect and defend the Constitution and it doesn’t make any difference if you’re a clerk, cook or rifleman. There should be no difference in classification when it comes to obtaining health care. Just as a side note, President George

Bush would not be eligible for VA health care if a ‘‘core constituency’’ is set up. I

would encourage Senator Salazar as a member of the U.S. Senate Committee on

Veterans Affairs to fight and stop this slap in the face of all those Veterans who

have helped preserve the safety and freedoms of this country from non-combat place

or at a non-combat time.

Finally, I would like to suggest an idea that might solve some of the VA health

care funding. Could the VA set up some sort of VA health care insurance plan? The

plan could include low minimum premium paid by any veteran that signed up. The

insurance would only be for the veteran, but it would allow the veteran to be treated

at any medical facility. The insurance funding pool would come from the premiums,

money from the VA, and veterans Medicaid and Medicare benefits could also be

added to the pool. This way any veteran that signed up and paid premiums would

be covered at any medical facility with that facility receiving payment from only one

entity, the VA insurance.

Again thank you for the opportunity to express my views on the VA health care

system. Hopefully these suggestions will help you in your efforts to make health

care better and available to all veterans in the State of Colorado.

Senator SALAZAR. Thank you, Mr. Stanko. Thank you very much.

Mr. Leonard.

34

STATEMENT OF GEORGE LEONARD, WORLD WAR II VETERAN,

DURANGO, CO

Mr. LEONARD. Mr. Stanko saved my day. I have got the same

idea, make it local control. I am sorry for laughing, but he went

through the same thing I was going to talk about.

But I did haul veterans here into Grand Junction, and I can

guarantee you that the roads do get pretty hairy. If we could make

some kind of a deal with doctors, and whatnot, and hospitals in our

own area, that would save time, money and expense and wear and

tear on the drivers. It would be a lot safer. And he’s covered most

of it right there.

Senator SALAZAR. I appreciate your attendance, and appreciate

the passion of that advocacy that both of you share for veterans

and for the veterans particularly in northwest Colorado.

Chairman Richards.

STATEMENT OF HOWARD RICHARDS, SOUTHERN UTE INDIAN

TRIBE PAST CHAIRMAN, VIETNAM VET, IGNACIO, CO

Mr. RICHARDS. Good morning, Mr. Senator, my fellow comrades

here in attendance today. I would like to thank you for allowing me

to testify on behalf of the Southern Ute Veterans’ Association of the

Southern Ute Indian tribe.

I am an enrolled member of the Southern Ute Indian Tribe and

cofounder of the Veterans Association, which was formed—primarily the mission was to assist tribal veterans in the following

areas: Health, training and housing because of the inability of the

county Veterans’ Service Officers to meet the needs of a tribal veteran. I will speak a little to that as I move forward.

In 1994 the Southern Ute Tribal Council upon the urging of the

association funded a Tribal Veterans’ Service’s Officer position to

assist both tribal and non-tribal veterans on the education of veterans’ benefits and other issues.

I would like to add until the Veterans’ Administration can address our concerns of veterans of yesterday and today, and, most

important, future veterans, they will always find themselves between a rock and a hard place.

Now, I am going to speak toward a bullet point that I provided

to this Committee labeled ‘‘Entitlement and Benefits‘‘:

As Indian tribes, as sovereign nations, we should have the ability

for a government-to-government consultation with the Veterans’

Administration. That’s probably our biggest push in the Association

that the southern Ute Indian Tribe should speak directly to the

VA. Because when you get to the County Veterans’ Officers and

other people involved in the system, it slows the system down.

With the ability that is found under 1990, President Clinton’s executive order in respect to government-to-government relationship, I

think we need to start there with the Southern Ute Tribe and the

VA.

The other issues that I want to speak to are the means tests,

which is to include income guidelines, eligibility requirements on

income level, and the $25,000 threshold they have for eligibility. I

will come back to that one, and I am going to expound on that a

little bit.

35

I have talked and I have heard today about memorandums of understanding with other Federal agencies to include the Indian

health and the VA. I am yet to see an agreement that stipulates

how that is going to work. I have heard talk about it today. We

have asked for that document, and I don’t know where it’s at.

The other issue, very briefly, is I think the native population or

the American Indian has to have some representation or a position

on the rating board with respect to claims.

Also, I think that the Southern Ute Indian Tribe’s future participation on committee appointments, whether at the State or Federal

level, is probably a must. Because as the VA moves forward, the

VSO’s move forward, I believe that the Native American is somewhat left out in their discussion, in the dialog. Because we as native people or Indian tribes are unique, Mr. Senator, and you

talked about tradition and customs when we look at health issues.

The utilization of medicine men in treatment of our people of our

aches and pains are there. They are probably not part of the system in the VA, that we are unique and we need specialized medicine, if you want to call it that.

So when we talk about the threshold and the eligibility requirements outlined in the means test, that because as the tribe moves

forward in its development and its wealth that the future veteran

if he didn’t sign up within a period of time will not get enrolled in

the VA system.

I think that concludes my testimony, Mr. Chairman, and I look

forward to working with this committee as we move forward.

Right now, very quickly in closing, that the tribe has recognized

that the Indian Health Service, they are located in Ignacio, is not

meeting the needs of the Indian population, the Southern Ute Tribal population. So the tribe is in the process of contracting Indian

health from the government for that reason. It’s the hope of the

Southern Ute Tribal Council that each and every veteran, each and

every tribal member as we move forward in developing our health

benefit package for tribal members, that we can carry a card,

what’s illustrated, and that’s coming down very quickly. That you

can present that to any doctor of your choice for your medical treatment, because of the problems that we are seeing, not only with

the VA, but with the Veterans’ Administration and Indian Health.

So, in closing, Mr. Senator, I want to thank you for the short

time that you allowed me to testify before you. Thank you.

[The prepared statement of Mr. Richards follows:]

PREPARED STATEMENT OF HOWARD RICHARDS, SOUTHERN UTE INDIAN TRIBE

PAST CHAIRMAN, VIETNAM VET, IGNACIO, CO

First, I would like to thank this committee for allowing me to testify today on behalf of the Southern Ute Veterans Association of the Southern Ute Indian Tribe.

Second, my name is Howard D. Richards, Sr. and I am an enrolled member of

the Southern Ute Indian Tribe. I am one of the co-founders of the Southern Ute Veterans Association.

Third, the formation of the Southern Ute Veterans Association’s primary mission

was to assist Southern Ute Indian Tribal veterans in the following areas: (1) Health,

(2) Training, and (3) Housing. Another reason for the formation of the association

was the county’s veteran’s service officer inability to meet our tribal veterans’ needs.

Fourth, in 1994, the Southern Ute Tribal Council upon the urging of the Southern

Ute Veterans Association funded a tribal veteran service officer’s position. This position assisted both tribal and non-tribal veterans on the education of veteran’s benefits and other issues.

36

In conclusion, I would like to add: until the Veterans Administration, (VA) can

address our concerns of veterans of yesterday and today and most important future

veterans they will find themselves between a ‘‘Rock and A Hard Place’’.

ENTITLEMENTS/BENEFITS

• Tribal: Federal Government Relationship. (Gov’t to Gov’t). EX Order, 1990.

President Bill Clinton.

• Means Test: Income Guidelines; Eligibility Requirements-Income Level; and

$25,000.00 Threshold.

Senator SALAZAR. Thank you very much, Chairman Richards.

We will now hear from Paula Rothman.

STATEMENT OF PAULA ROTHMAN, GULF WAR VETERAN,

GRAND JUNCTION, CO

Ms. ROTHMAN. Thank you. I would like to start, Senator Salazar,

by thanking you for all the work you are doing to help veterans receive better health care.

Shortly after I returned from the Persian Gulf War, I was diagnosed with a disease called scleroderma. From 1992 to 2000 I used

the VA hospital in Tampa, Florida.

Scleroderma is a disease that is best followed by a rheumatologist. Because the VA hospital in Tampa had a number of different fellows, internships, internists all participating as part of

the USF training program from the medical school there, I wasn’t

able to see the doctor every quarter.

So I requested fee basis, and they went ahead and sent me out

to a specific rheumatologist so I could see the same rheumatologist

every quarter.

In 2002 I moved to Grand Junction. A large part of my decision

to move to Grand Junction included my access to care and the fact

that there was a large VA hospital here. It was really a disappointment for me to learn that the VA here did not contract with a

rheumatologist to see patients. Instead, they expect patients to

travel to Denver, to Salt Lake City for rheumatology care.

I have traveled to Denver for care in 2004, and I cannot remember if I also did in 2003. But I requested fee basis for a rheumatologist here in Grand Junction. I was denied, although Dr. Clark, my

primary care physician, requested this from the Chief of Staff here.

I appealed this decision through the patient advocate and was then

denied again in October 2004. I was told they denied the request

because there were no long-term rheumatologists in Grand Junction, and they did not want my care to suffer.

Scleroderma is a serious illness that should be tracked by a

rheumatologist. However, as a full-time employee it’s very difficult

for me to travel to Denver. In Tampa I was told that I should be

seen quarterly, and I have seen a rheumatologist since I moved to

Grand Junction once or twice. I can’t remember exactly which.

I don’t feel it’s appropriate for me to take a full day off from work

every quarter to drive, you know, 10 hours round trip to Denver

and then however long it takes for me to wait to see the

rheumatologist in Denver.

In addition to scleroderma, I have had two melanomas and a carcinoma. The dermatologist noted those moles when I was in Tampa

and requested that they get removed. I didn’t point them out. As

a board-certified dermatologist, he noted them and said, ‘‘These

37

need to come off.’’ Unfortunately, the VA hospital in Grand Junction does not have a dermatologist on staff from what I have been

told. I am sure the doctor at the Grand Junction VA hospital, I am

sure they are very competent at their specialties, and I appreciate

all the care I get from Dr. Clark whom I respect very much.

However, the dermatologist in Tampa practicing in his specialty

noted the changes in these moles and he likely saved my life by

removing them. I am not positive my general practitioner, Dr.

Clark, would be as adept at noting these changes.

In preparation for my testimony on August 12th, I contacted the

patient advocate at the Grand Junction VA hospital to ensure my

testimony would be correct. He brought this to the attention of the

Chief of Staff. On that day he actually reopened my appeal and approved me for fee-basis care. So now I am able to see a rheumatologist using fee basis as of last Monday, even though my appeal was

closed almost a year ago.

I feel my care at the VA Hospital in Grand Junction is very good

in certain areas and lacking in others. I have wonderful access to

my primary care physician, Dr. Clark. Her nurse has always called

me back within 24 hours, usually much faster. Whenever I have

had appointments the care I have received is very thorough.

However, the lack of an onsite rheumatologist and dermatologist

is a serious weakness in my health care. This weakness could be

mitigated by using a fee-basis program to ensure all veterans get

the care they need or by hiring these specialists for monthly clinics.

I was paid approximately $50 for travel the last time I drove to

Denver, and this is just slightly less than the specialist I went to

see in Tampa was receiving. I think she was receiving about $60-

$80 depending on the length of my time.

Thank you for the opportunity to speak before you.

[The prepared statement of Ms. Rothman follows:]

PREPARED STATEMENT OF PAULA ROTHMAN, GULF WAR VETERAN,

GRAND JUNCTION, CO

I was diagnosed with a service-connected illness called Scleroderma shortly after

separating from the Army. From 1992 until 2000, I used the VA hospital in Tampa

and was approved for fee-basis care as Scleroderma is an illness that is best followed by one Rheumatologist. I was concerned in Tampa that I was being seen by

a different specialist on most visits. The Tampa VA is a teaching hospital associated

with the University of South Florida Medical School and the large number of interns, residents, and fellows made it difficult to maintain continuity of care. Therefore, I requested and was granted the ability to consult a Tampa Rheumatologist

under the fee basis program so that I would see the same doctor each visit.

In 2002, I moved to Grand Junction. A large part of my decision to move to Grand

Junction included my access to care and the fact that there was a large VA hospital

here. It was quite a disappointment to learn the VA hospital has not contracted

with a Rheumatologist in Grand Junction to see patients. Instead, they expect patients to travel to Denver or Salt Lake City for Rheumatology care. I have traveled

to Denver for care but in 2004 (or possibly 2003); I requested fee basis visits to a

Rheumatologist here in Grand Junction. I was denied, though Dr. Clark requested

it from the Chief of Staff. I appealed this decision through the patient advocate and

was denied again. I was told they denied the request because there were no longterm Rheumatologists in Grand Junction and they did not want my care to suffer.

Scleroderma is a serious illness that should be tracked by a Rheumatologist. However, as a full-time employee, it is very difficult for me to travel to Denver. In

Tampa, I was told I should be seen quarterly to track my illness, but I have seen

a Rheumatologist one to two times since I moved to Grand Junction solely due to

the hardship of traveling to Denver. I do not feel it is appropriate to take a full day

38

off from work quarterly for 10 hours worth of travel and the time it takes to wait

and see the doctor in Denver.

In addition to Scleroderma, I have had three serious cancers that required treatment including two moles with melanoma and one with basil cell carcinoma. I was

lucky that these were caught early after seeing a Dermatologist in Tampa as part

of the VA hospital fee-basis program. This Dermatologist noted the moles and suggested they were removed.

Unfortunately, the VA hospital in Grand Junction does not have a Dermatologist

on staff. I am sure the doctors at the Grand Junction VA hospital are very competent at their specialty and I appreciate all the care I get from Dr Clark, who I

respect and appreciate very much. However, the Dermatologist in Tampa practicing

in his specialty noted the changes in my moles and likely has saved my life by removing them. I am not positive a General Practitioner/Internist is as adept at noting these kinds of skin changes as a board certified Dermatologist would be as this

is not the specialty of a General Practitioner/Internist.

Note: In preparation for my testimony on August 12, 2005, I called the Patient

Advocate on at the Grand Junction VA hospital to ensure my testimony would be

correct. He brought this to the attention of the Chief of Staff and informed me in

a call later that my appeal has now been approved and I would be granted the ability to see a Rheumatologist as part of the fee basis program. After this call, I requested a referral from Dr. Clark to see a fee-basis Dermatologist and this request

is pending currently.

SUMMARY

I feel my care at the VA hospital in Grand Junction is very good in certain areas

and seriously lacking in others. I have wonderful access to my Primary Care Physician, Dr. Clark. Her nurse has always called me back within 24 hours for non-emergencies (usually much faster) and when I have had appointments, the care I have

received is very thorough. Dr. Clark is and will continue to be my primary care physician even though I will have access to a Rheumatologist on a fee-basis case in the

future. I would not want it any other way as I have all the respect in the world

for the care I receive from Dr Clark.

However, the lack of an onsite Rheumatologist and Dermatologist is a serious

weakness in my health care. This weakness could be mitigated by using a fee-basis

program to ensure all veterans get the care they need or by hiring these specialists

for monthly clinics. I was paid approximately $50 for travel to and from Denver the

last time I drove there, and this is just slightly less than what these specialists get

paid for ongoing care consultations, if my memory from Tampa is correct.

I would be glad to answer any questions you may have.

Senator SALAZAR. Thank you, Ms. Rothman, for your testimony.

Mr. Stroncek.

STATEMENT OF HANK STRONCEK, WORLD WAR II VETERAN,

STEAMBOAT SPRINGS, CO

Mr. STRONCEK. Mr. Salazar, I think Jim Stanko and, what’s his

name, Condie said it all for me and for all of the guys from Routt

County and around the area.

On the way coming down here, there was a car in front of us

coming—as we left Hayden, and a deer came out. He spun around

in front of us, and he went close to the ditch, he went over to the

side, and he came back out again. We had to throw our brakes on

and stop so we didn’t plow into him.

In another instance we came down about 2 years ago. We were

going about 60 miles an hour, had a flat tire, and we nearly rolled

it, and we came out OK. Nothing happened.

But I would like to have it come into Steamboat to take care of

us instead of driving back here. Because one day we might get

banged up and, you know, never come back to the hospital. They

may haul us back in a wagon. I am not very much of a speaker

to speak of. Jim is good, Condie is good, but, me, I am just, forget

it.

39

Senator SALAZAR. Not at all, Mr. Stroncek, you are very good,

and what you say is very true. Yesterday I just came down that

same route, and I think we probably saw eight or nine deer close

to the road. I can imagine traveling that same route late at night

when it’s dark. As a person who has not only run into deer with

horses on roadways, I know exactly what you are talking about. I

very much appreciate your testimony this morning, and thank you.

Mr. STRONCEK. I voted for you. I am glad that Peter never got

in. Thank God. That’s all I got to say. Good luck, God bless you,

and carry on.

Senator SALAZAR. Thank you for your service to our country and

your testimony this morning.

Mr. Yoast, I would like to hear from you.

STATEMENT OF LEONARD YOAST, WORLD WAR II VETERAN,

HAYDEN, CO

Mr. YOAST. Well, I have very great respect for the hospital here

in Grand Junction. My wife was a veteran in Germany, which I

was a veteran in Japan, over in the islands, rather. We would come

down to this hospital. We averaged about every 2 weeks between

the two of us when she was in bad shape. I have lost her 7 years

and 6 months today.

The trip was terrible. Sometimes it was icy. In the summertime,

when they were working on the roads, we would be stalled.

I would like to get a place in Steamboat Springs, a clinic or a

hospital, or Craig. Someplace where it was close. It was 194 miles

from my house to the Veterans’ Hospital here in Grand Junction.

But, they were always nice here in Grand Junction, the hospital

was. The doctors, the nurses, were especially nice. But it took us

a long time and hard trips to get here.

I’ve lost my wife now. I come with Michael Condie, and he has

been wonderful. He’s really been a great help to us. I would like

to get something started in either Craig or Steamboat Springs so

we wouldn’t have to go so far. Because when you get 85 years old,

you just don’t feel like going that far. Thank you very much.

Senator SALAZAR. Well, I thank you very much, Mr. Yoast, for

making the sacrifices you made for our country and your wife as

well and for continuing to do good by appearing before our committee today to provide us your testimony. It’s very much appreciated.

Mr. YOAST. OK. Thank you.

Senator SALAZAR. Mr. Adams.

STATEMENT OF MICHAEL ADAMS, IRAQ WAR VETERAN,

NORWOOD, CO

Mr. ADAMS. Thank you very much. I think I would like to take

the few moments that I have to address a couple of issues.

First of all, support for what I have heard here today, the distance, the travel that is involved, the expense, the difficulty the

veterans face living in a rural community and having to travel for

their health care, I certainly would support fee-based systems so

that they could stay within their community and receive their primary health care while still having access to the VA medical sysVerDate 11-MAY-2000 13:20 May 04, 2006 Jkt 025787 PO 00000 Frm 00043 Fmt 6633 Sfmt 6601 C:\VA\25787.TXT CarolB PsN: CarolB
40

tem for their inpatient rehab or other more sophisticated needs

that they might have.

I would also like to take a couple of minutes to speak to some

of the veterans that are returning right now from this crisis in

Iraq. There are particular—when you are coming back as a National Guard or Reserve soldier, you come back, you take your

leave, you are getting re-integrated with your family, with your job.

It is very difficult to get the time off to go and travel to get signed

up into the system. If you came back with issues such as Post

Traumatic Stress Disorder, depression, anxiety as a result of your

service, you are trying to balance the needs of your family, trying

to get re-integrated into job, and to take a day off to get back is

very difficult. So, again, I would support more community-based

services for our returning veterans as well as the other veterans we

have heard here.

I also find it somewhat likely that, particularly for the primary

care kinds of issues, that it would be less expensive if we could

keep them in the community rather than going through the cost

and needs of setting up elaborate transportation systems in order

to transfer these people throughout the State to go to highly centralized areas. I think the centralized model works good in an

urban environment where there is a high population density and

public transportation is available. But I think when you are talking

about a community with these numbers of miles and special needs

of the veterans in these communities, that we need to look into

those communities to find at least some of those answers.

I would like to thank you for having me here today.

[The prepared statement of Mr. Adams follows:]

PREPARED STATEMENT OF MICHAEL ADAMS, IRAQ WAR VETERAN, NORWOOD, CO

As both a medical provider and a veteran of the Iraqi Conflict, it is my personnel

belief that this country has an obligation to support its veterans.

Veteran health care services are currently centered in urban areas, where it is

more cost efficient to treat a large number of patients at a limited number of sites.

However, this model overlooks a sub-group of vets who live in small rural communities, many who are found here in western Colorado. Providing medical services to

these vets have a number of unique challenges, including: Distance to approved

service facilities; Limited travel capabilities of an aging population; Isolated Geography of the Western Slope; and Weather, sometimes severe, creating further isolation.

These challenges are further complicated by poor or declining health, and the limited incomes of many of our veterans.

Our veterans need a strong system of central services such as a patient medical

care, advanced diagnostics, rehab services. In rural area, this could be enhanced

with partnership with community-based medical services. Services should be focused

on primary care, allowing vets to seek their primary care and follow up services in

their community, rather than traveling, at a minimum of several hours, and often

overnight for the veterans and their families, to obtain care.

In addition, community-based mental health services to help returning services

personnel with mental health issues should be available. Returning service personnel have been placed under great stress. Frequent and extended deployments result in numerous problems and issues of depression, PTSD and raising divorce

rates.

Nonetheless, I have often seen veterans who choose not to be treated for primary

and mental health services, due to the complications of travel for older veterans, the

lost time from work and family for younger veterans, and the health and financial

means to be able to travel for many veterans. Services available to veterans through

existing community services would improve the health and outcomes of many of our

veterans living in isolated rural communities. I would appreciate your consideration

41

of the needs of these veterans, who although not the majority, are entitled to recognition of their service to our nation.

Thank You.

Senator SALAZAR. Thank you very much, Mr. Adams. I thank

each and every one of you for your testimony. I want to make a

few closing comments at the end of this hearing:

I found the hearing very informative. I found the testimony that

has been given to us by the officials you have heard from today,

as well as our veterans, to be very informative to me. I am certain

that my colleagues and friends on this committee, both Democrats

and Republicans, hear the concern. That concern being how we can

better serve the veterans who live in rural Colorado who are sometimes far away from the medical facilities that can provide their

care.

I take from this hearing a tremendous amount of information

and issues that I will work on with my colleagues including looking

at the suggestions that were made by several of you that we might

create an Office of Veterans Affairs that deals specifically with the

rural health care issue for veterans, i.e., hearing the cry for additional services in places that are remote, such as northwest Colorado.

I have heard that same cry for services in places in northeast

Colorado and places like Julesburg and Yuma and Wray. I hear

that cry definitely here in the western slope.

I hear the discussion and even the debate about whether we

should move forward with a CBOC in northwest Colorado or figure

out ways of doing fee-for-service contracts with the local hospitals

in that area. That’s certainly something I am confident is on the

radar screen of Veterans’ Affairs. So the issues and concerns that

we have raised here today for me as one of your United States Senators who sit on the Veterans’ Affairs Committee has been very

valuable to me.

Let me just in closing for this hearing remind you that if you

have additional testimony that you might want to provide, and to

those of you who did not get to testify today, I ask that you provide

your testimony for us for the record, and we will keep the record

open until some time passes to give you that opportunity.

Finally, you know, for me one of the things that has always been

a reality is that I told people that we need to understand that the

world doesn’t begin and end in Colorado Springs or in Denver, Colorado. That there is a whole other Colorado out there that is very

much an America and a Colorado that has a set of struggles that

we don’t often see in the huge metropolitan areas.

I always tell people in meetings that I have had in the capital

in Denver that if you happen to live among that population of 2.8

million people and you have a meeting on Saturday morning at 8

o’clock in the capital, you can get up in the morning and go to your

meeting, and by noon you go about your business.

But if you happen to live in Craig, in Dove Creek, in Durango,

in Trinidad, in my native valley, in Conejos County, in Julesburg,

that same 8 o’clock meeting on a Saturday morning becomes an inevitable 1-day and most of the time a 2-day trip. Because you have

to go there on a Friday night, stay over, go to your meeting. By the

time you drive back, it’s an additional 5, 6, 7, 8 hours. In fact, if

42

you are in Dove Creek, Colorado you are about 9 hours away from

our capital. If you are in Craig, Colorado, you are probably 41⁄2

hours away from our capital.

So I understand that reality, and I believe that my colleagues on

this Committee have an understanding about the challenges that

face rural America and that face our rural veterans.

Senator Larry Craig, for example, is from Idaho. He is a Republican with many of the same issues that we talk about here are

similar kinds of issues that they face in Idaho.

Senator Danny Akaka is a World War II veteran and one of the

heroes of our Senate. He understands the importance of making

sure that all veterans are served in every way possible and that

the vision of serving each and every veteran is important to all of

us.

I look very much forward to working with my colleagues on this

Committee to address issues and concerns that you have raised.

This is not the last of the meetings, at least, that I will have with

all of you. Because these issues are important, and I will continue

to work on them in the years ahead.

I thank you very much for your participation here this morning.

Thank you.

Mr. WATKINS. Senator, I have something I would like to present

to you.

Senator SALAZAR. Mr. Watkins.

Mr. WATKINS. I would like to present that to you, Senator, to

take back to Washington.

Senator SALAZAR. Thank you very much, Charlie. It says, ‘‘The

Nation which forgets defenders will itself be forgotten.’’ So we must

never forget our veterans. Thank you so much.

The hearing is adjourned.

[Whereupon, at 11:34 a.m., the committee was adjourned.]

(43)

APPENDIX

PREPARED STATEMENT OF EARL MACKENZIE, PRESIDENT, LOCAL 1014,

AMERICAN FEDERATION OF GOVERNMENT EMPLOYEES, AFL–CIO

My name is Earl ‘‘Scottie’’ Mackenzie, and I am the President of Local 1014 of

the American Federation of Government Employees (AFGE) in Cheyenne, Wyoming

with field facilities in Colorado. AFGE represents more than 600,000 Federal employees who serve the American people across the Nation and around the world, including more than 150,000 employees of the Department of Veterans Affairs (VA).

Local 1014 represents 157 VA defined professionals and non-professionals, (they are

all professionals in my mind) in my bargaining unit. I want to extend my gratitude

to Senator Salazar for the opportunity to discuss our concerns about providing

health care to veterans in Colorado, and other distinguished members of the Senate

Veterans’ Affairs Committee.

THE CHALLENGES OF DELIVERING HEALTH CARE TO VETERANS IN COLORADO

Rural health care markets face significant challenges as compared to urban markets, including a limited number of specialists, less access to expensive technologies

and a less affluent patient population. At the same time, rural Americans are disproportionately represented in the military. Thus, it is no surprise that a disparity

in health care exists between veterans living in rural areas and their urban and

suburban counterparts. A recent study by public health experts found that veterans

living in rural areas experience a lower ‘‘health-related quality of life’’. As a result,

the veterans’ health care costs are estimated to be as high as 11 percent greater

in rural areas. Colorado has a higher share of share of rural veterans as compared

to the country as a whole—14.1 percent of veterans in Colorado reside in rural areas

as compared to the national average of 12.7 percent.

THE IMPACT OF BUDGET SHORTFALLS AND STAFFING CUTS

Reductions in funding and FTE’s affect our ability to care for veterans at the

VAMC as well as our CBOCs. Every location that becomes short-staffed results in

delays in appointments and backlogs in providing needed care.

Without adequate funding and FTE’s, we will not be able to operate new CBOCs

when they are opened. If we take staff away from existing CBOCs, we will simply

be shifting our staffing shortage and forcing other veterans to experience longer

waiting times.

Despite staffing shortages, our staff remains dedicated to the caring of our veterans. However, I also have to care about our dedicated employees who become ill

and stressed because of mandated overtime. These staff shortages have forced us

to hire agency staff, which cost the taxpayer more while impacting the quality of

care we deliver and the safety of our patients. Prolonged overtime and other pressures also cause older staff members to take early retirement, which further adds

to the staffing problem.

RECOMMENDATIONS ADDRESSING THE HEALTH CARE NEEDS OF VETERANS

IN RURAL COLORADO

The veterans in our State need new facilities and more staff to meet their medical

needs. Additional CBOCs will allow us to provide more timely care and reduce the

long distances that many veterans have to drive to see a doctor.

Expanding the use of telemedicine will complement, but cannot replace, these efforts to expand access. A telemedicine coordinator is needed to provide expanded

services and ensure adequate coordination with CBOCs and hospitals that are also

involved in treatment.

What will not help the rural veteran is an increased use of fee-based services as

a substitute for VAMC and COBC care. Fee-based care, except in the rare exception

44

when care is not available for a medical specialty or in a very remote area, is a bad

deal for the taxpayer as well as the patient. Throughout the country, VISNs have

found that fee basis services are significantly more expensive. In addition, these

services sometimes lack the quality and unique treatment that is available with the

VA facility. I challenge this VA committee to actually compare the actual FEE basis

care costs for this VISN. We have seen cost estimates as high as 35 percent more.

CONCLUSION

In closing, I thank you again for the opportunity to submit this written testimony

on behalf of all of the veterans and thank you also for holding this hearing in this

beautiful state. We at VAMC, weather it be in Grand Junction, Denver, Fort Collins, and Cheyenne will continue to provide the best of care for our veterans. Veterans deserve to have stable and sufficient funding for the medical care on which

they depend, as well as a system that provides adequate access to care for rural

communities.

July 10, 2005.

Hon. KEN SALAZAR,

225 North 5th St. Suite 511,

Grand Junction, CO 81501.

DEAR SENATOR SALAZAR: I have the opportunity today to address you as State

Commander of the Department of Colorado Veterans of Foreign Wars about some

of the needs of our Colorado veterans who live in the Northwest and Northeast part

of Colorado. Both of these areas have to travel in excess of 200 miles to receive medical attention.

Our aging WWII Veterans are at times in worst condition when they arrive home

after a 400–500-mile round trip to get a regular blood test or basic medical examination and medications. This is a problem we have been facing for some time with the

WWII Vets; however, the veterans of my era, the Korean Conflict, are now approaching the time when they are in need of more medical attention. The Viet Nam

veterans are approaching retirement age and their medical needs are also increasing. Present concerns we have now are with our Afghanistan and Iraq causalities

arriving home daily. The number of wounded, estimated from news reports, is

10,000–30,000 needing medical attention from losses not seen before in previous

wars or conflicts and requiring long-term medical attention.

Colorado has two sparsely populated areas: Northwest and Northeast Colorado

where veterans must travel at great distances to even get basic medical attention

such as blood and diabetes tests, medication checkups, etc. Northwest and Northeast Colorado need to have medical facilities within a few miles to serve the health

needs of our veterans. At one time there was a Colorado goal of Community Colleges

and Vocational Education was to have training for employment within a 30-mile

travel distance of every Colorado citizen. Do not Colorado veterans deserve the same

consideration? Colorado should at least have a facility to meet their basic medical

needs within 1 hour of their home.

Colorado needs a Community-Based Outreach Clinics (CBOC) System in the

Northwest and Northeast to meet the veterans’ needs. I would ask that there be

funding to meet the budgetary needs for these facilities.

At this time I would like to thank you for all of your hard work, Senator, for support of all the veterans of Colorado.

DARRELL ANDERSON,

State Commander,

Department of Colorado Veterans of Foreign Wars.

August 2005.

Hon. KEN SALAZAR,

225 North 5th St. Suite 511,

Grand Junction, CO 81501.

DEAR SENATOR SALAZAR: I am a retired Air Force Lt. Colonel and hospital administrator, a volunteer on the town medical board, a disabled veteran, and a resident

of a rural community. I believe I have the knowledge to understand what happens

for healthcare for veterans in a rural facility. I currently live in Lake City, Colorado,

a town with about 550 people, close to one-fifth of which are veterans—both male

and female. Yes we are small but we live a quiet beautiful life with a lot of benefits

45

city dwellers do not have, and we also do not have things the citizens of a city might

enjoy.

One thing many of us do not have is access to healthcare through the veteran’s

administration and many have no insurance at all. Jobs in Lake City are typically

seasonal, low paying, and definitely with no insurance. So what do they do for

healthcare? Nothing or pay as they go for care are their options and we all know

how expensive healthcare is so the second option is unlikely. That leaves doing

nothing and I would propose that is what most veterans are forced to do. They do

nothing, of course, until it is too late and then the illness is worse and they have

to make that trek to Montrose (good luck getting a same day appointment) or to

Grand Junction to the hospital. There the cost has got to be increased because the

illness is now worse or the injury more severe. It is the same syndrome that exists

with any underserved population, including Medicare (where the elderly cannot pay

the co-pay).

I would like to see every Lake City veteran have access to healthcare, here in

Lake City. We have one of the finest clinic’s I have ever been associated with and

the staff definitely wants everyone to receive care. Veterans would be able to not

only get care for most illnesses or injuries but for preventive care, as well. Prevention is the key to any healthcare program.

I am a very fortunate individual having access to several forms of insurance—

Medicare (because of my disability), Tricare (for being retired Air Force) and the

Veteran’s Administration. I am proud to say I have received the best overall care

from the Veteran’s Administration. This care from the VA includes care received in

both Lake City and Gunnison. Because of my 100 percent service-connected disability I have been afforded the option of care within the civilian community on a

‘fee for service basis.’ This care has been extremely important in preventing more

hospitalizations and illnesses that could seriously hamper my overall health.

I appreciate what I have and want the same for all my fellow veterans. Thank

you Senator Salazar for caring enough to ask the tough questions.

ERIN T. CAVIT.

STEAMBOAT MENTAL HEALTH CENTER,

Steamboat Springs, CO.

DEAR SENATOR SALAZAR: I am writing on behalf of Colorado West Regional Mental

Health Centers and the veterans living in the northwest of Colorado. I am the Frontier Division Director with Colorado West RMHC and am responsible for the community mental health services in four rural counties; Routt, Moffat, Rio Blanco, and

Jackson. There are veteran residents in each of these counties and the population

of veterans is growing.

Access to mental health services for veterans as part of their veteran’s benefits

has always been difficult. Sufferers have to travel to Grand Junction to receive care

at the VA Medical Center and its related clinics, or travel to the Front Range. This

travel is not only difficult, especially during winter months, but impedes best practices care if they want to have care covered by their benefits.

Several members of the veteran’s community have expressed to me a desire to receive mental health care in this area either from the Veterans Administration or

have an agreement to have the care provided locally by local providers. This letter

is to offer strong support for this concept of local care. Colorado West RMHC has

offices in each of the counties listed above and has psychiatrists and therapists with

the training to help these veterans with most of their mental health needs. With

the type and variety of mental health care available locally it does not seem appropriate that veterans should have to travel as much as 200 miles to receive mental

health care.

I encourage the VA to consider a model in which veterans can receive the mental

health care they need locally by utilizing the local providers who understand both

mental issues and the community in which the veterans live.

I am unable to attend your meeting on August 16 in grand Junction (I am hosting

meeting on grass roots political efforts for our mental health services in Colorado

with the Mental-Health Association of Colorado), however I hope you will take this

letter as a declaration of support ad willingness to provide services locally to the

veterans residing in the Frontier Division of Colorado West RMHC.

TOM GANGEL,

Division Director,

Colorado West Regional Mental Health, Inc.

46

YAMPA VALLEY MEDICAL CENTER,

August 1, 2005.

Hon. KEN SALAZAR,

U.S. Senate,

Washington, DC.

DEAR SENATOR SALAZAR: I am writing this letter on behalf of Yampa Valley Medical Center and the veterans residing in northwest Colorado. For many years, veterans living in our portion of the State have not had easy access to physicians or

hospitals providing services as part of their veterans’ benefits. Most must make the

significant drive to Grand Junction to receive care at the VA Medical Center and

its related clinics, or to the Front Range. This significant travel is quite disruptive

to the veteran, their families and their employers when they must seek care to be

covered as part of their veterans benefits.

As I am the CEO at Yampa Valley Medical Center, I know there has been an interest on the part of area veterans to have a Veterans Administration presence, or

arrangement in this area, to allow for care to be provided locally. This letter is to

offer strong support to this concept. In Steamboat Springs, all primary care and specialty physicians are independent practitioners. Yampa Valley Medical Center does

not employ nor operate any physician clinics. YVMC does, however, offer extensive

diagnostic services and the broad array of services that can be provided by our 55

members of the medical staff that address more than 25 different specialties. With

this type of local capabilities, it seems inappropriate not to be able to provide

healthcare services to our veterans locally.

Yampa Valley Medical Center has been on record with former Representative

McGinness and Senators Nighthorse Campbell and Allard in being willing to work

with the Veterans Administration to enter into contractual arrangements to provide

service. This commitment and interest continues. Additionally, while I cannot speak

for them individually, I am confident that the members of the medical community

in Steamboat Springs would be interested in working with the VA to develop relationships that allow for the existing medical community to provide services to those

veterans in our area. The medical community of Steamboat Springs serves not only

our community, but serves as a regional resource center for the five counties of

northwestern Colorado.

It is my understanding that the standard model utilized by VA when it establishes outreach clinics is to create a clinic environment and provide direct staffing

to that clinic with VA physicians. I would encourage the VA to consider an alternative model utilizing the existing physicians and diagnostic services within the

community rather than duplicating services already in existence.

I am sorry. I am unable to attend your meeting to discuss this topic on August

16th; however, I hope you will take this letter in the spirit of interest and cooperation in working with the Veterans Administration to bring services closer to the

homes of our veterans.

Sincerely,

KARL B. GILLS,

Chief Executive Officer.

HINSDALE COUNTY,

August 1, 2005.

HON. KEN SALAZAR: As the Hinsdale County Veterans Service Officer in Lake

City, Colorado, I wish to express my views concerning veterans’ health care in rural

communities. I greatly appreciate this opportunity to do so.

For years I have been an advocate of allowing veterans who reside in rural areas

to access healthcare in their own communities.

The fairly recent opening of the VA clinic in Montrose reduced the travel distance

for veterans’ healthcare, but the more than 200-mile round trip to access healthcare

in Montrose remains a burden for Hinsdale County veterans. My main concern is

that the trip is hazardous, especially in winter and more so for our elderly veterans.

The distance problem is compounded for our working veterans. The 4-hour plus

travel time usually means a full day of work lost for a 15 minute or so appointment.

It could turn into an overnight stay if required to travel to Grand.

Residents take pride in the excellent facilities and staff at the Lake City Area

Medical Center. It is located in town within walking distance of most that use it.

Although veterans pay taxes to maintain the facility, they are not able to use it

while taking advantage of their VA benefits.

On a personal note, I am a disabled veteran. Prior to the opening of the Montrose

clinic, I was able to have routine checkups and prescription renewals done at the

47

Lake City Area Medical Center for my service-connected disabilities. This was done

under the Fee-Basis, or Non-VA Care program. I am no longer able to take advantage of this program and must travel to Montrose or Grand Junction if necessary.

As a disabled veteran I am eligible to receive reimbursement for travel, meals and

lodging for service-connected healthcare. I would love to have these payments be

used for office visits at the local medical center.

Thank you for this opportunity to express my views on behalf of Hinsdale County

veterans.

Sincerely,

PAUL G. OLSON,

Hinsdale County Veterans Service Officer.

August 17, 2005.

Hon. KEN SALAZAR,

U.S. Senate,

Washington, DC.

DEAR SENATOR SALAZAR: The most effective contribution to the health of our veterans would be to make VA medical contracts available at local hospitals and clinics

in rural areas.

Perhaps the greatest hardship upon these veterans is the necessary travel for

medical care in these rural areas.

The current transportation arrangements are of benefit to many veterans, but do

not include their spouses or support persons who are an important part of their

health-care support team. Many times the people have to take unpaid leave from

their jobs in order to travel with their spouses to VA hospitals and clinics for critical

or routine care. These, in addition to the rising transportation costs at present, are

a definite hardship for those whose income is already stretched to the limit Being

able to access health care locally would be the most important veterans benefit to

come out of this session of Congress. Please continue to work toward this goal on

behalf of all of us in Western Colorado as well as other rural areas.

We are very fortunate to have you and John Salazar representing Colorado in

Washington.

Best regards,

T.A. OTTMAN, USMC,

Korean Conflict.

DEPARTMENT OF COLORADO,

Denver, CO, August 8, 2005.

DEAR SENATOR SALAZAR: I am writing on behalf of all veterans who have answered their Country’s Call and served honorably in the armed forces. When we entered the service we were not given assignments based on where we had previously

lived, but rather based on the needs of the service. We all were subject to being

placed in harms way and served where ordered.

While serving, and when we left the service, we were all told that there would

be health care available to us for the rest of our lives through the Veteran’s Administration. There was no mention of limitations based on where we chose to live.

At the present time there is great disparity in the quantity and quality of health

care a veteran can receive based solely on where the veteran lives. Only our elected

Senators and Congressmen can bring about the equality we fought for.

You can do this by passing legislation which will require the Veteran’s Administration to contract with local health care providers to provide Community-Based

Outpatient Clinics whenever a veteran must travel more than 100 miles round trip

to a Veteran’s Administration Medical Facility. (In medicine there is a ‘‘Golden

Hour’’ rule which states that if a patient receives definitive medical care within 1

hour of an emergency, the patient’s chances of a successful outcome are much greater than if there is more than an hour delay in obtaining medical treatment.) Great

travel distances to a VA Medical Facility deprive many veterans of this level of care.

The American Legion, Department of Colorado, and all veterans living more than

100 miles from a VA Medical Facility applaud your efforts and will support the intent of the legislation you have proposed in Senate Bill 1191.

This legislation, as presently proposed, will fill a need to permit us to continue

to provide veterans with a way to get to a VA Medical Facility and to obtain the

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care they earned with their service to our nation. We believe this is a temporary

solution to a permanent problem.

GAR WILLIAMS,

Department Jr. Vice Commander.

THE MEMORIAL HOSPITAL,

Craig, Colorado, August 8, 2005.

Mr. GAR WILLIAMS, Vice-Commander,

Colorado American Legion Post,

Craig, CO.

DEAR MR. WILLIAMS: The Memorial Hospital has previously established its position as being supportive of facilitating a community-based outreach clinic in support

of local veterans. This topic came up a few years ago and the Administrator of the

Hospital at that time agreed to sit down with the Veterans Administration officials

to discuss and negotiate an arrangement that would enable local Veterans to receive

primary care in our community. At that time, no one from the VA ever approached

the Hospital to have the necessary conversation. On behalf of the Hospital, I am

again extending the offer to discuss this possibility with the VA.

Sincerely Yours,

SUE LYSTER,

Chair, Board of Trustees.

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